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Based on staff interviews, record review, observations, review of facility policies and procedures, administrative fall reviews (including performance improvement data and internal investigations), the facility failed to protect the Patients Right to receive care in a safe setting for patients at risk of falls. The facility failed to ensure adequate supervision by nursing for sampled patients 1,2,3, and 7 and 16 of 102 (Observation 5/14/19) non sampled patients (identified by nursing assessments at high risk for falls). The 20 patients failed to have interventions to protect patients from falls implemented in accordance with the high risk for falls and facility fall prevention policy. Patient 1, on 4 North nursing unit, fell 4/17/18, no bed alarm sounded to alert staff, the patient sustained fractures to right arm. Patient 2, on Medical Surgical ICU, fell on 5/5/19, the bed alarm did not sound, the patient sustained an arterial laceration to the right temple with profuse bleeding, small bleed to the brain, right wrist fracture, fractured pelvis and rib fractures on the right side causing a pneumothorax (abnormal collection of air in the pleural space between the lung and the chest wall that can limit lung expansion). The pneumothorax required insertion of a chest tube to expand the lung. Patient 3, on 4 North, fell 3/25/19, the bed alarm did not sound, the patient fell on the surgical stump (below knee amputation 4 days prior) causing the incision to come apart and return to surgery for repair. Patient 7, Trauma ICU, fell 3/24/19, bed alarm had been discontinued based on error in fall risk assessment. The fall caused the Foley (urinary catheter) and Intravenous (IV) lines to be pulled out. The patient had a feeding tube through the abdomen which was pulled taught. The staff failed to ensure the tube was infusing into the gastroinstestinal tract post fall which resulted in tube feeding formula causing an infection and 5 surgical procedures to repair. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Patient Rights was not met, and that Immediate Jeopardy (IJ) conditions existed at this facility since 3/24/19, posing a threat of potential serious injury, harm, impairment or death of patients admitted with high fall risk factors. The total sample size was 10. The facility census was 267. See also A144.

The failure to implement immediate effective action plans had the potential to affect the care of all patients in the facility. The administrative staff implemented measures to remove the immediate jeopardy noncompliance on 5/16/19 by implementing the following:

A. Action to Mitigate: Ensure compliance with Fall Prevention and Risk for Injury Policy

- Educate identified staff on key elements of Fall Prevention Program to include expectation that for patients with a Morse > or equal to 46; and /or at risk for injury (ABCS indicating Age/Fragility, Bones, coagulation, Surgery); and /or who are confused, impulsive, cannot teach back fall prevention instructions or have a condition such that, at the nurses' discretion, would indicate further intervention (e.g. frequent changes in patient's cognitive status), the following must be implemented in addition to universal high risk interventions; bed/chair alarm; scheduled toileting;remain within arm's reach and in sight while toileting. The following roles: RN, LPN, CNA, Student Nurse, Director, Supervisor, Educator Working in the following areas: Impatient med/Surg; ICU;PCU: OBS ( 2N, 3N/S/E, 4N/S/E, 5, 6 Float Pool; Enterprise Float Pool) will complete prior to working next shift or before 5/31/19. Employees who are on FMLA or leave will complete prior to returning to work.

- The following roles: RN, LPN, CNA, Student Nurse, Director, Supervisor, Educator Working in the following areas: Inpatient Med/Surg; ICU; PCU; OBS ( 2N, 3N/S/E, 4 N/S/E, 5, 6, Float Pool, Enterprise Float Pool) will read the Fall Prevention and Risk for Injury policy and sign an attestation acknowledging that they have read and understand the Fall Prevention and Risk for Injury policy prior to working next shift or before 5/31/19. Employees who are on FMLA or leave will complete prior to return to work.

High Risk Patients require: Call light and personal items within reach; bed in low position; both upper side rails up -do not use 4 side rails; hourly rounding; yellow arm band ; yellow socks; yellow door sign; gait belt in room and in use when patient ambulates.
For those with a Morse> or equal to 46 and/or at high risk for injury must have in addition: Bed & Chair alarms on 100% of the time; Never leave alone in bathroom/shower; scheduled toileting; consider a bedside 1:1 sitter; consider a low bed with floor pads. Bed & chair alarms are checked with each hourly round; bedside report with each handoff; after a patient has moved to bed or to chair or to bathroom/commode. Check if alarm is on and is it working.

-Leadership to conduct visual observation and medical record documentation audit to ensure compliance with fall prevention interventions, provide real time coaching, with results to be reviewed daily with senior leadership at Bed Huddle. The audit tool identifies the documented fall score; visualize fall band; visualize yellow socks; visualize Gait Belt in room; visualize bed alarm visual sign/ visualize bed/chair alarm on and audible/ Indicate level of Bed/Chair Alarm (lying/sitting standing appropriate?); Low bed implemented (Y; N=not indicated; X = not implemented but indicated and implemented post audit); Fall assessment completed after condition change or procedure altering LOC [level of consciousness]; Medical record document of fall prevention plan of care and interventions present.

Action to Mitigate: Ensure that staff utilize low beds when indicated.

- Educate staff on process to obtain low beds (online module) The following roles: RN, LPN, Director, Supervisor, Educator Working in the following areas (Inpatient Me/Surg; ICU, PCU, OBS (2N, 3N/S/E, 4 N/S/E, 5, 6, Float Pool, Enterprise Float Pool) will complete prior to working next shift or before 5/31/19. Employees who are on FMLA or leave will complete prior to return to work.
-Implement plan to ensure low bed is available, to include initial 4 bed par level with plan to obtain additional reserve beds when there are 3 beds on reserve. EVS will monitor usage and report number of beds on reserve daily and report out at daily safety huddle.

Immediate actions following identification of fall on 5/6/19 [Patient 2] included daily audit of fall prevention interventions occurring on 100% of patients in Med/Surg ICU [location of Patient 2 when fall occurred]; review expectations at daily management board; leader rounding for fall prevention intervention validation.

B. On 5/16/19 surveyors observed 51 patients with high fall risk scores from 9:15 -10:45 AM. 100% had interventions in place. Interviews with 6 staff nurses and 1 charge nurse confirmed they had the education required in the facility action plan. Review of leadership audits conducted 5/16/19 also confirmed compliance with the action plan. Review of the attestations for staff confirmed they were done as per action plan. CMS abated the IJ on 5/16/19

Based on staff interviews, record review, observations, review of facility policies and procedures, administrative fall reviews (including performance improvement data and internal investigations), the facility failed to protect the Patients Right to receive care in a safe setting for patients at risk of falls. The facility failed to ensure adequate supervision by nursing for sampled patients 1,2,3, and 7 and 16 of 102 (Observation 5/14/19) non sampled patients (identified by nursing assessments at high risk for falls). The 20 patients failed to have interventions to protect patients from falls implemented in accordance with the high risk for falls and facility fall prevention policy. Patient 1, on 4 North nursing unit, fell 4/17/18, no bed alarm sounded to alert staff, the patient sustained fracture to right arm. Patient 2, on Medical Surgical ICU, fell on 5/5/19, the bed alarm did not sound, the patient sustained an arterial laceration to the right temple with profuse bleeding, small bleed to the brain, right wrist fracture, fractured pelvis and rib fractures on the right side causing a pneumothorax (abnormal collection of air in the pleural space between the lung and the chest wall that can limit lung expansion). The pneumothorax required insertion of a chest tube to expand the lung. Patient 3, on 4 North, fell 3/25/19, the bed alarm did not sound, the patient fell on the surgical stump (below knee amputation 4 days prior) causing the incision to come apart and return to surgery for repair. Patient 7, Trauma ICU, fell 3/24/19, bed alarm had been discontinued based on error in fall risk assessment. The fall caused the Foley (urinary catheter) and Intravenous (IV) lines to be pulled out. The patient had a feeding tube through the abdomen which was pulled taught. The staff failed to ensure the tube was infusing into the gastroinstestinal tract post fall which resulted in tube feeding formula causing an infection and 5 surgical procedures to repair. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that Immediate Jeopardy (IJ) conditions existed at this facility since 3/24/19, posing a threat of potential serious injury, harm, impairment or death of patients admitted with high fall risk factors. The total sample size was 10. The facility census was 267.

The failure to implement immediate effective action plans had the potential to affect the care of all patients in the facility. The administrative staff implemented measures to remove the immediate jeopardy noncompliance on 5/16/19. See A0115

A. Record review revealed Patient 1 was admitted to the medical floor of 4 North on 4/15/19 for acute kidney injury, stroke, vascular dementia. The nursing care plan identified fall risk as a problem. Fall risk score was 85 high risk ( Morse Fall risk score greater than or equal to 46 is considered high risk) on 4/15/19 at 5:00 PM. Interventions added included bed/chair alarm, no skid yellow socks, gait belt, low bed position and purposeful rounding. Review of documented fall interventions found that the patient had fall scores of 100 beginning at 8:00 AM on 4/16/19 The intervention documentation of alarm use showed the alarm was not in use on 4/16/19 at 8 AM, was in use at 8:00 PM, and not in use on 4/17/19 at 8 :00 AM. Nursing documentation on 4/17/19 at 9:01 AM notes the physician was "Notified of Fall @ 0750. Dr. assessed pt [patient] at 0830". The note further states the patients Power of Attorney (POA) was notified of the fall at 8:59 AM. There are no other notes in the record by nursing related to the fall. Review of Physician Progress notes on 4/17/19 at 8:59 AM state the patient was "found down in the bathroom. Bed alarm did not sound." The Physician notes the patient had "bruising along the right elbow and forearm. Does have palpable ridge on right side of scalp." X-Ray of the right elbow showed a "minimally impacted right radius neck fracture." Nursing documentation of high fall risk interventions post fall at 8:55 PM failed to include the use of the bed/chair alarm.
Interview with Registered Nurse A, a nursing supervisor on 5/15/19 at 4:15 PM confirmed that at the time of the fall the alarm did not sound.

B. Record review revealed Patient 2 was admitted to the Medical Intensive Care Unit (ICU) on 5/2/18 with diagnosis of hepatic encephalopathy ( a brain disorder caused by advanced liver disease), cirrhosis of the liver, Gastro intestinal bleeding and chronic kidney disease. The nursing care plan identified the patient was at risk for falls on 5/3/19. The care plan included "Institute fall precautions as indicated by assessment". On 5/5/19 the physician changed the level of care from ICU to Progressive Care Unit (PCU) status, however the patient remained in the ICU. Nursing documentation by Registered Nurse (RN) B on 5/5/19 at 10:45 PM notes the nurse heard a noise and found the patient on ground next to the bed face down. Bleeding was observed from a laceration on the scalp, multiple lacerations on the right upper extremity. RN B noted the patient was initially unresponsive. A staff emergency was called with physician and other nursing staff responding. The patient's neck was secured in a C-collar, the patient put on a back board and placed back on the bed. Physician progress notes the patient suffered an unwitnessed fall and hit her head. Testing and further assessment identified the patient suffered a 3 centimeter (cm) laceration to the right temporal area with pulsitile arterial bleeding -repaired by Trauma Surgery staff, CT scans showed a new small right frontal and medial left frontal subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain) -Neurosurgery consult examined the patient found her to be awake and alert, no surgery needed. The patient also had multiple acute rib fractures on the right side, pubic rami (pelvic bone) fractures, and a right radial/wrist fracture- Orthopedic consult noted the fractures were non displaced and put a splint on the right wrist. A left sided pneumothorax was also found and required placement of a chest tube to re-expand the lung on 5/6/19. Pulmonary Critical Care physician noted on 5/6/19 at 12:54 AM that due to the blood loss the patient required blood transfusions. The patients blood pressure dropped after the fall but responded to Normal Saline Intravenous (IV) fluids and transfusions. The patient was alert but confused throughout her stay. Social work notes on 5/7/19 at 5:21 PM note that the family and patient have requested transfer to [Name of Hospital B]. The notes state "The patient and family are frustrated with the patient's fall and feels that the patient would get better care at [name of Hospital B] The patient transferred on 5/7/19.
Interview with RN B on 5/15/19 at 8:30 AM. RN B was assigned to Patient 1 on 5/5/19 when the patient fell. RN B stated the patient was not disoriented other than not knowing why she was in the hospital. In report from the previous nurse she was not told the patient had confusion. RN B recalled the patient was using the call light to use the bedpan. The fall assessment was done at 8 PM and she was a high fall risk (score 100). Interventions included a "bed alarm on, was supposed to be on at all times." RN B stated "all patients at high risk are to have bed alarms/chair alarms." RN B stated that " when I got the patient on the bedpan I had turned the alarm off - not sure when I turned it off." RN B recalled she was outside of the patient's room and heard a thud. She was face down on the floor on the right side. There were 2 side rails up on that side and she went over them. Initially she was not responding. Oxygen was applied and she slowly woke up over the next 5 -10 minutes. She was confused to person, place and time. Once she was put back on the bed the bed alarm was turned on.

C. Record review revealed Patient 3 was admitted to Medical Unit 4 North on 3/18/19 for Diabetic ulcer to the right foot with osteomylitis (bone infection). The physician orders 3/18/19 included "fall precautions." Fall risk was included in the plan of care on admission. On 3/19/19 at 8:00 PM the fall risk score was up to 50 (high risk). Record review of Operative Reports notes the patient had a right below knee amputation on 3/20/19. Fall risk assessment on 3/20/19 at 2:00 PM was higher at 95. Interventions included use of bed/chair alarm. Fall risk scores on 3/21 were 95 however, use of bed/chair alarm intervention was not documented. Review of fall interventions on 3/22 - 3/24/19 fails to identify consistent use of the bed/chair alarms with fall scores of 95. On 3/21/19 at 7:21 AM the patient/family were educated to call for assistance with mobility. On 3/24/19 at 7:55 PM the fall score was 75 with the intervention of bed/chair alarm not documented. The risk scoring also noted the patient was on anticoagulant (blood thinners). Nurses Notes document that on 3/25/19 at 3:02 AM RN C documented hearing the patient and family yell and a thud to the floor. RN C ran to the room and found the patient on the floor with the walker lying next to him. The surgical incision (amputation site) was dehisced (split open). A Medical Emergency Team was called. The patient was assessed and a pressure dressing applied to the stump. The patient was assisted back to bed. The bed alarm was then activated, the bed in the low position, side rails up X 2, call light in reach. RN C noted "fall precautions in place." Operative notes on 3/25/19 note the patient had to have surgical repair noting that "the entirety of the skin an fascia [a band of connective tissue beneath the skin]had been dehisced and the bone exposed."
Interview with RN A, who assisted with the record review, on 5/15/19 at 4:15 PM confirmed the fall score was high at 95 and the bed alarm was not activated.

D. Record review revealed Patient 7 was admitted on 3/16/19 to the Trauma ICU following a motor vehicle accident resulting in a mid-sternal fracture, lumbar 4-6 rib fractures, nasal bone and spine fracture, and fractures of the jaw. He had a tracheostomy tube inserted, a PEG inserted 3/19/19 (Percutaneous endoscopic gastrostomy tube -passed into the stomach through the abdominal wall to provide a means of nourishment), jaws wired shut, and Foley (urinary) catheter. Initially he was on a ventilator. Physician progress notes 3/24/19 at 10:27 AM that plan was to wean the patient off of the ventilator today, he was afebrile and jaws remained wired shut. The patient was fed formula through the PEG to meet nutritional needs. The physician noted Patient 1 was awake and communicative by writing, pain controlled and "intermittently agitated per nurse." Fall risk was included in the plan of care. Fall scores demonstrated high risk until 3/23/19 at 11:00 PM when the score was 35. The score changed due to nursing lowering the score related to the patient as being oriented to his own abilities and will call for help to get up. Review of the cognitive assessment by nursing on 3/23/19 at 11:00 PM noted the patient was awake and alert and "unable to assess orientation." This error in scoring the patient's fall risk at 35 continued on 3/24/19 at 7:20 PM. The patient was no longer on high fall risk precautions and did not have a bed alarm on per fall risk documentation. The ABCS risk factors, indicating high risk for fall with injury, for this patient included B for bone fractures and C for Coagulation (Patient was on Lovexox, an anticoagulant daily). Had the ABCS risk factors been considered the patient would have remained a high fall risk and a high fall risk for injury and included use of a bed alarm.
Record review of facility document titled "Safety First Event Classification" notes the patient fell on 3/24/19 at 10:00 PM. The document states that the RN went into the room to check on why the Blood Pressure monitor did not cycle for 10:00 PM and 10:05 PM blood pressures. The nurse "found the patient sitting on bottom on floor in stool., Patient had pulled out Foley and peripheral IV and removed all monitoring chords." He was assisted back to bed and cleaned up. Since his jaw was wired shut he communicated through nods/gestures that he did not hit his head. He wrote on his whiteboard that he needed to have a bowel movement, but dropped his call light off the bed. He decided to get up and fell. He also said "he felt like he did not want to live like this post traumatic injury from MVA." He was at moderate fall risk. Contributing factors were documented as "altered mental status." Impulsive behaviors was also noted.
Nursing documentation by the patient's nurse, RN D, noted the physician was notified of the fall on 3/24/19 at 10:22 PM. Orders were given to replace the Foley. At 11:15 PM the physician was notified that the nurse was unable to insert the Foley. Review of Nursing documentation of the PEG on 3/24/19 noted that prior to the fall the insertion site was healing and open to air. The tube feeding was continuous Pivot 1.5 formula infusing continuously full strength at 55 cc (cubic centimeters) per hour. Nursing documentation notes the patient's tube feeding was restarted at 1:30 AM per physician. The record has no order to start the tube feeding. The record notes that the feeding was infusing at 55 cc per hour. Nursing Notes at 4:00 AM note the patient is complaining of flank and abdominal pain. RN D clamped off the tube feeding noting 170 cc had infused. The physician is notified and contrast injection of the gastric tube by radiology is ordered to evaluate "flank pain and G-tube position." At 5:00 AM the patient's surgical resident physician is notified of a positive sepsis screen (sepsis is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). The patient now had a fever of 101.3 Fahrenheit, a rapid pulse 123 and rapid respirations of 35. The nursing documentation on 3/25/19 shows that from 1:00 AM - 6 :00 AM the patient received 170 cc of formula and 60 cc of water into the PEG tube. At 5:00 AM the record shows the surgical resident saw the patient but there are no notes by the resident.
The Radiology contrast injection of the PEG is done at 12:01 PM on 3/25/19. The test shows the contrast (dye) is seen "spilling into the subcutaneous tissues of the left upper quadrant of the G-tube insertion site." The tip of the tube "appears to be in the superficial soft tissues." Subcutaneous emphysema (air trapped under the skin) is seen 'throughout the left abdomen." At 2:09 PM a CT of the abdomen and pelvis with contrast is done. The CT results noted "Gastrostomy tube balloon is in the body wall with extensive subcutaneous emphysema. Trauma Surgery physician documented on 3/25/19 at 3:33 PM that the patient was "agitated and fell last night. Tugged on PEG tube." The provider removed the PEG tube at the bedside and sent the patient to interventional radiology for placement of a new PEG. As a result of the PEG tube becoming dislodged during the fall the tube feeding was restarted without verification of placement resulting in formula infusing into the patient's abdominal tissues causing pain, fever and infection. The patient had 5 surgical procedures to treat the abdominal infection and abscess. Surgery irrigation and debridement of abdomen was performed on 3/27 and 4/3/19. Incision and drainage with irrigation and debridement of abdominal wall abscess with wound vac application on 4/5/19. Left abdominal wound exploration, debridement, irrigation with wound vac dressing exchange on 4/8/19. Left abdominal wound abscess/exploration/debridement/washout and vac dressing change on 4/12/19. The patient discharged 4/16/19 to a Rehabilitation Hospital.
Telephone interview with RN D on 5/15/19 at 4:00 PM recalled the fall of patient 1 on 3/24/19. The nurse found the patient on the floor, pulled out Foley and IV. Monitoring chords were on the floor. The tube feeding PEG was hooked up (infusion pump) but was taught. He used the whiteboard and said his call light fell on floor. It was wrapped around the side rail and low on the bed. The patient had 2 side rails up on one side and 1 on the other side. He got out on the side with 1 rail. The nurse confirmed her fall score was 35 low risk. She identified the scoring factors were lowered from 20 points for mental status to zero points because the patient was calling appropriately when help was needed. She confirmed the patient does not ambulate at night. She confirmed being assigned the patient for the past 3 nights and he was calling appropriately without an alarm. The nurse noted that after the fall she pressed on the patient's abdomen and her assessment was negative for any abdominal concerns. Later in the shift the patient complained of abdominal pain so she stopped the tube feeding and notified the physician. RN D confirmed she gave the patient 235 cc of tube feeding and 60 ml of water during her 12 hour shift beginning on 3/24/19 at 6:30 PM. The nurse stated she did not put in an order to stop the tube feeding but did pass it on to the day shift. Tests were ordered in the morning by the day physician team. The nurse said she checked for residual (aspirating the PEG tube to assess for contents in the stomach) at the beginning of the shift and did it again before giving med's and flush (documented at 8:00 PM). The nurse stated she felt the tube feeding was infusing appropriately by the infusion pump because it did not alarm.

E. Observations on 5/14/19 from 1:30 PM to 3:05 PM of 105 patients whose last fall assessment identified them as having a fall risk score of 46 or higher revealed 16 patients failed to have high risk fall interventions in place. Nursing Units who had patients without the bed or chair alarm activated included 2 patients on Trauma ICU, 2 patients on 2 North Medical Surgical Unit, 3 on HVI (Heart Vascular Institute) Unit and 4 on 4th floor. 2 Patients on HVI failed to have fall risk identification bracelets on. 4 patients on 4th floor failed to have on yellow anti slip socks. Note 1 patient on 4th floor did not have an alarm activated and did not have the yellow socks on. During tour on 5/14/19 at 1:50 PM on the Trauma ICU unit one of the non sampled patients was observed in bed without the fall alarm activated. The fall score was high at 50 per facility documentation. Interview with the RN F assigned to the patient stated "I repositioned him and forgot to turn the alarm back on."

F. Review of facility policy titled "Fall and Risk for Injury Interventions" last revised 5/17 notes High Risk for Fall Prevention Plan Interventions for patients with a Morse Fall Score of 46 or higher include "Colored (yellow) arm band, colored (yellow) non -skid socks; when assistance needed use a gait belt; For patients who are confused, impulsive, or cannot teach back fall prevention instructions, recommend the following: Bed and chair alarms, scheduled toileting, remain with patient at arms length and in sight while toileting; Floor pad as needed ; Evaluate need for low bed; Campus-specific fall signage outside the door of room; Fall indicator signage inside room and visible to patient; Consult Physical Therapy, Occupational therapy, if warranted; Evaluate need for assessing orthostatic blood pressure ;Evaluate need for medication review.
For patients at High Risk for Injury the "ABCS"assessment tool is used. The tool was last revised 2/18. The assessment tool notes that "if any of the boxes are checked the patient is considered a high risk for injury from falls. A - Age 85 years or greater;
B - Bones: History of fractures, certain diagnoses, treatments or medications that cause bones to become weak; C - Coagulation: History of Cancer, blood thinners, coagulopathy or renal dialysis. Examples are blood thinners Coumadin, Plavix, Heparin, Lovenox, Eliquis; S - Surgical post op within 72 hours of surgery.

G. Record review of the Quality Assurance fall dashboard data for 11/2018 to 5/2019 shows the highest number of falls are on the HVI. Number of falls peaked in March 2019 at 34. April had 31 and as of 5/13/19 there had been 14 falls. Disabled alarms were a contributing factor for 6 falls falls. 3 falls were considered "serious safety events".

The facility failed to have an effective Quality Assessment and Performance Improvement Program. This finding was based on record review of the facility Quality assurance plan and procedure for serious safety events, staff interviews and record review of the facility action plan developed post fall of Patient 2 on 5/5/19 in the Medical ICU. Patient 2, a high fall risk patient, failed to have the bed alarm activated and fell resulting in multiple fractures and a collapsed lung. On 5/6/19 the facility implemented an immediate action plan to ensure fall precautions were in place for the Intensive Care Unit (ICU) only to prevent further falls and injuries. The failure to ensure the immediate action plan was implemented to all units placed all patients at high fall risk at risk of falls/injuries. Review of patient falls data and grievances found 3 ( Patient 1, 3 and 7) other patients with falls resulting in harm with injuries since 3/24/19. Patient 1, on 4 North nursing unit, fell 4/17/18, no bed alarm sounded to alert staff, the patient sustained fractures to right arm. Patient 3, on 4 North, fell 3/25/19, the bed alarm did not sound, the patient fell on the surgical stump (below knee amputation 4 days prior) causing the incision to come apart and return to surgery for repair. Patient 7, Trauma ICU, fell 3/24/19, bed alarm had been discontinued based on error in fall risk assessment. The fall caused the Foley (urinary catheter) and Intravenous (IV) lines to be pulled out. The patient had a feeding tube through the abdomen which was pulled taught. The staff failed to ensure the tube was infusing into the gastrointestinal tract post fall which resulted in tube feeding formula causing an infection and 5 surgical procedures to repair. The serious adverse patient safety events with Patient 1,3 and 7 were not addressed through quality to prevent harm to others. Failure to identify and address serious adverse safety events has the potential to affect all patients. These failures resulted in a determination by Centers for Medicare and Medicaid that the Condition of Participation for Quality Assurance was not met. The sample size was 10. The facility census was 267. See also A 115 and A 385.

A. Interview with the Director of Quality and Safety 5/13/19 at 10:00 AM revealed the fall of Patient 2 was the facility's only major harm fall since 2/14/19. The Director stated we are investigating the fall. Root Cause Analysis (RCA) was scheduled for 5/13/19. The Director stated Patient 2 was the "only Major harm fall since 2/14/19."

B. Interview with Registered Nurse (RN) G, the ICU Nursing Director, on 5/13/19 at 1:05 PM confirmed Patient 2 had an unwitnessed fall. The bed alarm was not activated. RN G stated they did an Immediate Code E (immediate internal review with leaders, risk, quality and staff if indicated to mitigate further occurrence) with review of what happened on 5/6/19 beginning the RCA Process. The nurses caring for Patient 2 were interviewed on 5/7/19. The immediate action plan implemented by RN G on 5/6/19 was to do 100% of ICU patient audits daily to ensure all fall measures were in place. Review of audits identified the patients fall score with 0-45 having universal fall precautions. Those with scores of 46 or higher are high risk and require high risk interventions. The audits included fall score, (yellow)fall alert band on the patient, (yellow) non skid socks, Gait belt in the room, Bed alarm sign, Bed/chair alarm activated. Audit data demonstrated improvement in the implementation of fall precautions when reviewed on 5/13/19.

C. Record review of Quality Data for falls since 2/14/19 revealed Patient 1 with a fractured arm on 4/17/19 was moderate harm. Patient 3 who required surgery to repair the injury to his recent below the knee amputation incision was moderate harm. Patient 7 who fell on 3/24/19 dislodged his feeding tube resulting in infection and abscess from the feeding formula going into the abdomen. The patient required 5 surgical procedures to treat the infection.. Patient 7 was not listed at all on the fall list with harm.
Interview with the Division Director of Risk 5/15/19 at 2:40 PM regarding Patient 7 stated that the incident report showed "no harm and no one went back and changed it to show he had harm." There were no action plans developed after the falls of Patient 1,3 and 7.

D. Record review of the facility "Quality, Safety, and Performance Improvement Plan" last reviewed 8/18 under the section titled
"Model/Methods of Improvement" states "A collaborative approach to patient safety, risk management and quality includes procedures for responding to system and /or process failures, defining sentinel events and conducting appropriate thorough and credible root cause analyses and response to these or other events." The plan further states that lessons learned from root cause analyses, system, and/or process failures "are disseminated to team members who provide related services." The Safety First Root Cause Analysis (RCA) Investigation Worksheet states "Where could the same or similar risks exist (both within the facility and within other facilities in the division)/ Ensure that action plan addresses all areas where the condition exists."

E.. Interview 5/14/19 with the system Vice President of Quality at 1:20 PM confirmed the facility failed to take the immediate action plan developed for ICU throughout the facility until after the RCA was done on 5/13/19. The 100% audits of all units is scheduled to start on 5/14/19 at 7:30 AM. Further interview on 5/15/19 at 9:35 AM revealed the facility is "starting over on our fall program." We are taking the program facility wide. The Vice President of Quality stated the facility rolled out a fall program in 2/18 however , nursing leaders who were here when the fall program was implemented last year are no longer here and the program fell apart."

Based on record review of the facility Quality assurance plan and procedure for serious safety events, staff interviews and record review of the facility action plan developed post fall of Patient 2 on 5/5/19 in the Medical ICU. Patient 2, a high fall risk patient, failed to have the bed alarm activated and fell resulting in multiple fractures and a collapsed lung. On 5/6/19 the facility implemented an immediate action plan to ensure fall precautions were in place for the Intensive Care Unit (ICU) only to prevent further falls and injuries. The failure to ensure the immediate action plan was implemented to all units placed all patients at high fall risk at risk of falls/injuries. Review of patient falls data and grievances found 3 ( Patient 1, 3 and 7) other patients with falls resulting in adverse patient events since 3/24/19. Patient 1, on 4 North nursing unit, fell 4/17/18, no bed alarm sounded to alert staff, the patient sustained fractures to right arm. Patient 3, on 4 North, fell 3/25/19, the bed alarm did not sound, the patient fell on the surgical stump (below knee amputation 4 days prior) causing the incision to come apart and return to surgery for repair. Patient 7, Trauma ICU, fell 3/24/19, bed alarm had been discontinued based on error in fall risk assessment. The fall caused the Foley (urinary catheter) and Intravenous (IV) lines to be pulled out. The patient had a feeding tube through the abdomen which was pulled taught. The staff failed to ensure the tube was infusing into the gastrointestinal tract post fall which resulted in tube feeding formula causing an infection and 5 surgical procedures to repair. The serious adverse patient safety events with Patient 1,3 and 7 were not addressed through quality to prevent harm to others. Failure to identify and address serious adverse safety events has the potential to affect all patients. The sample size was 10. The facility census was 267. See also A 115 and A 385.

A. Interview with the Director of Quality and Safety 5/13/19 at 10:00 AM revealed the fall of Patient 2 was the facility's only major harm fall since 2/14/19. The Director stated we are investigating the fall. Root Cause Analysis (RCA) was scheduled for 5/13/19. The Director stated Patient 2 was the "only Major harm fall since 2/14/19."

B. Interview with Registered Nurse (RN) G, the ICU Nursing Director, on 5/13/19 at 1:05 PM confirmed Patient 2 had an unwitnessed fall. The bed alarm was not activated. RN G stated they did an Immediate Code E (immediate internal review with leaders, risk, quality and staff if indicated to mitigate further occurrence) with review of what happened on 5/6/19 beginning the RCA Process. The nurses caring for Patient 2 were interviewed on 5/7/19. The immediate action plan implemented by RN G on 5/6/19 was to do 100% of ICU patient audits daily to ensure all fall measures were in place. Review of audits identified the patients fall score with 0-45 having universal fall precautions. Those with scores of 46 or higher are high risk and require high risk interventions. The audits included fall score, (yellow)fall alert band on the patient, (yellow) non skid socks, Gait belt in the room, Bed alarm sign, Bed/chair alarm activated. Audit data demonstrated improvement in the implementation of fall precautions when reviewed on 5/13/19.

C. Record review of Quality Data for falls since 2/14/19 revealed Patient 1 with a fractured arm on 4/17/19 was moderate harm. Patient 3 who required surgery to repair the injury to his recent below the knee amputation incision was moderate harm. Patient 7 who fell on 3/24/19 dislodged his feeding tube resulting in infection and abscess from the feeding formula going into the abdomen. The patient required 5 surgical procedures to treat the infection.. Patient 7 was not listed at all on the fall list with harm.
Interview with the Division Director of Risk 5/15/19 at 2:40 PM regarding Patient 7 stated that the incident report showed "no harm and no one went back and changed it to show he had harm." There were no action plans developed after the falls of Patient 1,3 and 7.

D. Record review of the facility "Quality, Safety, and Performance Improvement Plan" last reviewed 8/18 under the section titled
"Model/Methods of Improvement" states "A collaborative approach to patient safety, risk management and quality includes procedures for responding to system and /or process failures, defining sentinel events and conducting appropriate thorough and credible root cause analyses and response to these or other events." The plan further states that lessons learned from root cause analyses, system, and/or process failures "are disseminated to team members who provide related services." The Safety First Root Cause Analysis (RCA) Investigation Worksheet states "Where could the same or similar risks exist (both within the facility and within other facilities in the division)/ Ensure that action plan addresses all areas where the condition exists."

E.. Interview 5/14/19 with the system Vice President of Quality at 1:20 PM confirmed the facility failed to take the immediate action plan developed for ICU throughout the facility until after the RCA was done on 5/13/19. The 100% audits of all units is scheduled to start on 5/14/19 at 7:30 AM. Further interview on 5/15/19 at 9:35 AM revealed the facility is "starting over on our fall program." We are taking the program facility wide. The Vice President of Quality stated the facility rolled out a fall program in 2/18 however , nursing leaders who were here when the fall program was implemented last year are no longer here and the program fell apart."

Based on staff interviews, record review, observations, review of facility policies and procedures, administrative fall reviews (including performance improvement data and internal investigations), the facility failed to ensure adequate supervision by nursing to protect patients from falls for sampled patients 1,2,3, and 7 and 16 of 102 (Observation 5/14/19) non sampled patients (identified by nursing assessments at high risk for falls). The 20 patients failed to have interventions to protect patients from falls implemented in accordance with the plans of care for high fall risk and the facility fall prevention policy. Patient 1, on 4 North nursing unit, fell 4/17/18, no bed alarm sounded to alert staff, the patient sustained fractures to right arm. Patient 2, on Medical Surgical ICU, fell on 5/5/19, the bed alarm did not sound, the patient sustained an arterial laceration to the right temple with profuse bleeding, small bleed to the brain, right wrist fracture, fractured pelvis and rib fractures on the right side causing a pneumothorax (abnormal collection of air in the pleural space between the lung and the chest wall that can limit lung expansion). The pneumothorax required insertion of a chest tube to expand the lung. Patient 3, on 4 North, fell 3/25/19, the bed alarm did not sound, the patient fell on the surgical stump (below knee amputation 4 days prior) causing the incision to come apart and return to surgery for repair. Patient 7, Trauma ICU, fell 3/24/19, bed alarm had been discontinued based on error in fall risk assessment. The fall caused the Foley (urinary catheter) and Intravenous (IV) lines to be pulled out. The patient had a feeding tube through the abdomen which was pulled taught. The staff failed to ensure the tube was infusing into the gastroinstestinal tract post fall which resulted in tube feeding formula causing an infection and 5 surgical procedures to repair. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Nursing Services was not met, and that Immediate Jeopardy (IJ) conditions existed at this facility since 3/24/19, posing a threat of potential serious injury, harm, impairment or death of patients admitted with high fall risk factors. The total sample size was 10. The facility census was 267. See also A 144 and A395.

The failure to implement immediate effective action plans had the potential to affect the care of all patients in the facility. The administrative staff implemented measures to remove the immediate jeopardy noncompliance on 5/16/19 by implementing the following:

A. Action to Mitigate: Ensure compliance with Fall Prevention and Risk for Injury Policy

- Educate identified staff on key elements of Fall Prevention Program to include expectation that for patients with a Morse > or equal to 46; and /or at risk for injury (ABCS indicating Age/Fragility, Bones, coagulation, Surgery); and /or who are confused, impulsive, cannot teach back fall prevention instructions or have a condition such that, at the nurses' discretion, would indicate further intervention (e.g. frequent changes in patient's cognitive status), the following must be implemented in addition to universal high risk interventions; bed/chair alarm; scheduled toileting;remain within arm's reach and in sight while toileting. The following roles: RN, LPN, CNA, Student Nurse, Director, Supervisor, Educator Working in the following areas: Impatient med/Surg; ICU;PCU: OBS ( 2N, 3N/S/E, 4N/S/E, 5, 6 Float Pool; Enterprise Float Pool) will complete prior to working next shift or before 5/31/19. Employees who are on FMLA or leave will complete prior to returning to work.

- The following roles: RN, LPN, CNA, Student Nurse, Director, Supervisor, Educator Working in the following areas: Inpatient Med/Surg; ICU; PCU; OBS ( 2N, 3N/S/E, 4 N/S/E, 5, 6, Float Pool, Enterprise Float Pool) will read the Fall Prevention and Risk for Injury policy and sign an attestation acknowledging that they have read and understand the Fall Prevention and Risk for Injury policy prior to working next shift or before 5/31/19. Employees who are on FMLA or leave will complete prior to return to work.

High Risk Patients require: Call light and personal items within reach; bed in low position; both upper side rails up -do not use 4 side rails; hourly rounding; yellow arm band ; yellow socks; yellow door sign; gait belt in room and in use when patient ambulates.
For those with a Morse> or equal to 46 and/or at high risk for injury must have in addition: Bed & Chair alarms on 100% of the time; Never leave alone in bathroom/shower; scheduled toileting; consider a bedside 1:1 sitter; consider a low bed with floor pads. Bed & chair alarms are checked with each hourly round; bedside report with each handoff; after a patient has moved to bed or to chair or to bathroom/commode. Check if alarm is on and is it working.

-Leadership to conduct visual observation and medical record documentation audit to ensure compliance with fall prevention interventions, provide real time coaching, with results to be reviewed daily with senior leadership at Bed Huddle. The audit tool identifies the documented fall score; visualize fall band; visualize yellow socks; visualize Gait Belt in room; visualize bed alarm visual sign/ visualize bed/chair alarm on and audible/ Indicate level of Bed/Chair Alarm (lying/sitting standing appropriate?); Low bed implemented (Y; N=not indicated; X = not implemented but indicated and implemented post audit); Fall assessment completed after condition change or procedure altering LOC [level of consciousness]; Medical record document of fall prevention plan of care and interventions present.

Action to Mitigate: Ensure that staff utilize low beds when indicated.

- Educate staff on process to obtain low beds (online module) The following roles: RN, LPN, Director, Supervisor, Educator Working in the following areas (Inpatient Me/Surg; ICU, PCU, OBS (2N, 3N/S/E, 4 N/S/E, 5, 6, Float Pool, Enterprise Float Pool) will complete prior to working next shift or before 5/31/19. Employees who are on FMLA or leave will complete prior to return to work.
-Implement plan to ensure low bed is available, to include initial 4 bed par level with plan to obtain additional reserve beds when there are 3 beds on reserve. EVS will monitor usage and report number of beds on reserve daily and report out at daily safety huddle.

Immediate actions following identification of fall on 5/6/19 [Patient 2] included daily audit of fall prevention interventions occurring on 100% of patients in Med/Surg ICU [location of Patient 2 when fall occurred]; review expectations at daily management board; leader rounding for fall prevention intervention validation.

B. On 5/16/19 surveyors observed 51 patients with high fall risk scores from 9:15 -10:45 AM. 100% had interventions in place. Interviews with 6 staff nurses and 1 charge nurse confirmed they had the education required in the facility action plan. Review of leadership audits conducted 5/16/19 also confirmed compliance with the action plan. Review of the attestations for staff confirmed they were done as per action plan. CMS abated the IJ on 5/16/19

Based on staff interviews, record review, observations, review of facility policies and procedures, administrative fall reviews (including performance improvement data and internal investigations), the facility failed to ensure adequate supervision by nursing to protect patients from falls for sampled patients 1,2,3, and 7 and 16 of 102 (Observation 5/14/19) non sampled patients (identified by nursing assessments at high risk for falls). The 20 patients failed to have interventions to protect patients from falls implemented in accordance with the plans of care for high fall risk and the facility fall prevention policy. Patient 1, on 4 North nursing unit, fell 4/17/18, no bed alarm sounded to alert staff, the patient sustained fractures to right arm. Patient 2, on Medical Surgical ICU, fell on 5/5/19, the bed alarm did not sound, the patient sustained an arterial laceration to the right temple with profuse bleeding, small bleed to the brain, right wrist fracture, fractured pelvis and rib fractures on the right side causing a pneumothorax (abnormal collection of air in the pleural space between the lung and the chest wall that can limit lung expansion). The pneumothorax required insertion of a chest tube to expand the lung. Patient 3, on 4 North, fell 3/25/19, the bed alarm did not sound, the patient fell on the surgical stump (below knee amputation 4 days prior) causing the incision to come apart and return to surgery for repair. Patient 7, Trauma ICU, fell 3/24/19, bed alarm had been discontinued based on error in fall risk assessment. The fall caused the Foley (urinary catheter) and Intravenous (IV) lines to be pulled out. The patient had a feeding tube through the abdomen which was pulled taught. The staff failed to ensure the tube was infusing into the gastroinstestinal tract post fall which resulted in tube feeding formula causing an infection and 5 surgical procedures to repair. These failures resulted in the determination by that Immediate Jeopardy (IJ) conditions existed at this facility since 3/24/19, posing a threat of potential serious injury, harm, impairment or death of patients admitted with high fall risk factors. The total sample size was 10. The facility census was 267. See also A144 and A385

A. Record review revealed Patient 1 was admitted to the medical floor of 4 North on 4/15/19 for acute kidney injury, stroke, vascular dementia. The nursing care plan identified fall risk as a problem. Fall risk score was 85 high risk ( Morse Fall risk score greater than or equal to 46 is considered high risk) on 4/15/19 at 5:00 PM. Interventions added included bed/chair alarm, no skid yellow socks, gait belt, low bed position and purposeful rounding. Review of documented fall interventions found that the patient had fall scores of 100 beginning at 8:00 AM on 4/16/19 The intervention documentation of alarm use showed the alarm was not in use on 4/16/19 at 8 AM, was in use at 8:00 PM, and not in use on 4/17/19 at 8 :00 AM. Nursing documentation on 4/17/19 at 9:01 AM notes the physician was "Notified of Fall @ 0750. Dr. assessed pt [patient] at 0830". The note further states the patients Power of Attorney (POA) was notified of the fall at 8:59 AM. There are no other notes in the record by nursing related to the fall. Review of Physician Progress notes on 4/17/19 at 8:59 AM state the patient was "found down in the bathroom. Bed alarm did not sound." The Physician notes the patient had "bruising along the right elbow and forearm. Does have palpable ridge on right side of scalp." X-Ray of the right elbow showed a "minimally impacted right radius neck fracture." Nursing documentation of high fall risk interventions post fall at 8:55 PM failed to include the use of the bed/chair alarm.
Interview with Registered Nurse A, a nursing supervisor on 5/15/19 at 4:15 PM confirmed that at the time of the fall the alarm did not sound.

B. Record review revealed Patient 2 was admitted to the Medical Intensive Care Unit (ICU) on 5/2/18 with diagnosis of hepatic encephalopathy ( a brain disorder caused by advanced liver disease), cirrhosis of the liver, Gastro intestinal bleeding and chronic kidney disease. The nursing care plan identified the patient was at risk for falls on 5/3/19. The care plan included "Institute fall precautions as indicated by assessment". On 5/5/19 the physician changed the level of care from ICU to Progressive Care Unit (PCU) status, however the patient remained in the ICU. Nursing documentation by Registered Nurse (RN) B on 5/5/19 at 10:45
PM notes the nurse heard a noise and found the patient on ground next to the bed face down. Bleeding was observed from a laceration on the scalp, multiple lacerations on the right upper extremity. RN B noted the patient was initially unresponsive. A staff emergency was called with physician and other nursing staff responding. The patient's neck was secured in a C-collar, the patient put on a back board and placed back on the bed. Physician progress notes the patient suffered an unwitnessed fall and hit her head. Testing and further assessment identified the patient suffered a 3 centimeter (cm) laceration to the right temporal area with pulsitile arterial bleeding -repaired by Trauma Surgery staff, CT scans showed a new small right frontal and medial left frontal subarachnoid hemorrhage (bleeding between the brain and the tissue covering the brain) -Neurosurgery consult examined the patient found her to be awake and alert, no surgery needed. The patient also had multiple acute rib fractures on the right side, pubic rami (pelvic bone) fractures, and a right radial/wrist fracture- Orthopedic consult noted the fractures were non displaced and put a splint on the right wrist. A left sided pneumothorax was also found and required placement of a chest tube to re-expand the lung on 5/6/19. Pulmonary Critical Care physician noted on 5/6/19 at 12:54 AM that due to the blood loss the patient required blood transfusions. The patients blood pressure dropped after the fall but responded to Normal Saline Intravenous (IV) fluids and transfusions. The patient was alert but confused throughout her stay. Social work notes on 5/7/19 at 5:21 PM note that the family and patient have requested transfer to [Name of Hospital B]. The notes state "The patient and family are frustrated with the patient's fall and feels that the patient would get better care at [name of Hospital B] The patient transferred on 5/7/19.
Interview with RN B on 5/15/19 at 8:30 AM. RN B was assigned to Patient 1 on 5/5/19 when the patient fell. RN B stated the patient was not disoriented other than not knowing why she was in the hospital. In report from the previous nurse she was not told the patient had confusion. RN B recalled the patient was using the call light to use the bedpan. The fall assessment was done at 8 PM and she was a high fall risk (score 100). Interventions included a "bed alarm on, was supposed to be on at all times." RN B stated "all patients at high risk are to have bed alarms/chair alarms." RN B stated that " when I got the patient on the bedpan I had turned the alarm off - not sure when I turned it off." RN B recalled she was outside of the patient's room and heard a thud. She was face down on the floor on the right side. There were 2 side rails up on that side and she went over them. Initially she was not responding. Oxygen was applied and she slowly woke up over the next 5 -10 minutes. She was confused to person, place and time. Once she was put back on the bed the bed alarm was turned on.

C. Record review revealed Patient 3 was admitted to Medical Unit 4 North on 3/18/19 for Diabetic ulcer to the right foot with osteomylitis (bone infection). The physician orders 3/18/19 included "fall precautions." Fall risk was included in the plan of care on admission. On 3/19/19 at 8:00 PM the fall risk score was up to 50 (high risk). Record review of Operative Reports notes the patient had a right below knee amputation on 3/20/19. Fall risk assessment on 3/20/19 at 2:00 PM was higher at 95. Interventions included use of bed/chair alarm. Fall risk scores on 3/21 were 95 however, use of bed/chair alarm intervention was not documented. Review of fall interventions on 3/22 - 3/24/19 fails to identify consistent use of the bed/chair alarms with fall scores of 95. On 3/21/19 at 7:21 AM the patient/family were educated to call for assistance with mobility. On 3/24/19 at 7:55 PM the fall score was 75 with the intervention of bed/chair alarm not documented. The risk scoring also noted the patient was on anticoagulant (blood thinners). Nurses Notes document that on 3/25/19 at 3:02 AM RN C documented hearing the patient and family yell and a thud to the floor. RN C ran to the room and found the patient on the floor with the walker lying next to him. The surgical incision (amputation site) was dehisced (split open). A Medical Emergency Team was called. The patient was assessed and a pressure dressing applied to the stump. The patient was assisted back to bed. The bed alarm was then activated, the bed in the low position, side rails up X 2, call light in reach. RN C then noted "fall precautions in place." Operative notes on 3/25/19 note the patient had to have surgical repair noting that "the entirety of the skin an fascia [a band of connective tissue beneath the skin]had been dehisced and the bone exposed."
Interview with RN A, who assisted with the record review, on 5/15/19 at 4:15 PM confirmed the fall score was high at 95 and the bed alarm was not activated.

D. Record review revealed Patient 7 was admitted on 3/16/19 to the Trauma ICU following a motor vehicle accident resulting in a mid-sternal fracture, lumbar 4-6 rib fractures, nasal bone and spine fracture, and fractures of the jaw. He had a tracheostomy tube inserted, a PEG inserted 3/19/19 (Percutaneous endoscopic gastrostomy tube -passed into the stomach through the abdominal wall to provide a means of nourishment), jaws wired shut, and Foley (urinary) catheter. Initially he was on a ventilator. Physician progress notes 3/24/19 at 10:27 AM that plan was to wean the patient off of the ventilator today, he was afebrile and jaws remained wired shut. The patient was fed formula through the PEG to meet nutritional needs. The physician noted Patient 1 was awake and communicative by writing, pain controlled and "intermittently agitated per nurse." Fall risk was included in the plan of care. Fall scores demonstrated high risk until 3/23/19 at 11:00 PM when the score was 35. The score changed due to nursing lowering the score related to the patient as being oriented to his own abilities and will call for help to get up. Review of the cognitive assessment by nursing on 3/23/19 at 11:00 PM noted the patient was awake and alert and "unable to assess orientation." This error in scoring the patient's fall risk at 35 continued on 3/24/19 at 7:20 PM. The patient was no longer on high fall risk precautions and did not have a bed alarm on per fall risk documentation. The ABCS risk factors for this patient included B bone fractures and C for Coagulation (Patient was on Lovenox an anticoagulant daily). Had the ABCS risk factors been considered the patient would have remained a high fall risk and a high fall risk for injury and included use of a bed alarm.
Record review of facility document titled "Safety First Event Classification" notes the patient fell on 3/25/19 at 10:00 PM. The document states that the RN went into the room to check on why the Blood Pressure monitor did not cycle for 10:00 PM and 10:05 PM blood pressures. The nurse "found the patient sitting on bottom on floor in stool., Patient had pulled out Foley and peripheral IV and removed all monitoring chords." He was assisted back to bed and cleaned up. Since his jaw was wired shut he communicated through nods/gestures that he did not hit his head. He wrote on his whiteboard that he needed to have a bowel movement, but dropped his call light off the bed. He decided to get up and fell. He also said "he felt like he did not want to live like this post traumatic injury from MVA." He was at moderate fall risk. Contributing factors were documented as "altered mental status." Impulsive behaviors was also noted.
Nursing documentation by the patient's nurse, RN D, noted the physician was notified of the fall on 3/24/19 at 10:22 PM. Orders were given to replace the Foley. At 11:15 PM the physician was notified that the nurse was unable to insert the Foley. Review of Nursing documentation of the PEG on 3/24/19 noted that prior to the fall the insertion site was healing and open to air. The tube feeding was continuous Pivot 1.5 formula infusing continuously full strength at 55 cc (cubic centimeters) per hour. Nursing documentation notes the patient's tube feeding was restarted at 1:30 AM per physician. The record has no order to start the tube feeding. The record notes that the feeding was infusing at 55 cc per hour. Nursing Notes at 4:00 AM note the patient is complaining of flank and abdominal pain. RN D clamped off the tube feeding noting 170 cc had infused. The physician is notified and contrast injection of the gastric tube by radiology is ordered to evaluate "flank pain and G-tube position." At 5:00 AM the patient's surgical resident physician is notified of a positive sepsis screen (sepsis is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). The patient now had a fever of 101.3 Fahrenheit, a rapid pulse 123 and rapid respirations of 35. The nursing documentation on 3/25/19 shows that from 1:00 AM - 6 :00 AM the patient received 170 cc of formula and 60 cc of water into the PEG tube. At 5:00 AM the record shows the surgical resident saw the patient but there are no notes by the resident.
The Radiology contrast injection of the PEG is done at 12:01 PM on 3/25/19. The test shows the contrast (dye) is seen "spilling into the subcutaneous tissues of the left upper quadrant of the G-tube insertion site." The tip of the tube "appears to be in the superficial soft tissues." Subcutaneous emphysema (air trapped under the skin) is seen 'throughout the left abdomen." At 2:09 PM a CT of the abdomen and pelvis with contrast is done. The CT results noted "Gastrostomy tube balloon is in the body wall with extensive subcutaneous emphysema. Trauma Surgery physician documented on 3/25/19 at 3:33 PM that the patient was "agitated and fell last night. Tugged on PEG tube." The provider removed the PEG tube at the bedside and sent the patient to interventional radiology for placement of a new PEG. As a result of the PEG tube becoming dislodged during the fall the tube feeding was restarted without verification of placement resulting in formula infusing into the patient's abdominal tissues causing pain, fever and infection. The patient had 5 surgical procedures to treat the abdominal infection and abscess. Surgery irrigation and debridement of abdomen was performed on 3/27 and 4/3/19. Incision and drainage with irrigation and debridement of abdominal wall abscess with wound vac application on 4/5/19. Left abdominal wound exploration, debridement, irrigation with wound vac dressing exchange on 4/8/19. Left abdominal wound abscess/exploration/debridement/washout and vac dressing change on 4/12/19. The patient discharged 4/16/19 to a Rehabilitation Hospital.
Telephone interview with RN D on 5/15/19 at 4:00 PM recalled the fall of patient 1 on 3/24/19. The nurse found the patient on the floor, pulled out Foley and IV. Monitoring chords were on the floor. The tube feeding PEG was hooked up (infusion pump) but was taught. He used the whiteboard and said his call light fell on floor. It was wrapped around the side rail and low on the bed. The patient had 2 side rails up on one side and 1 on the other side. He got out on the side with 1 rail. The nurse confirmed her fall score was 35 low risk. She identified the scoring factors were lowered from 20 points for mental status to zero points because the patient was calling appropriately when help was needed. She confirmed the patient does not ambulate at night. She confirmed being assigned the patient for the past 3 nights and he was calling appropriately without an alarm. The nurse noted that after the fall she pressed on the patient's abdomen and her assessment was negative for any abdominal concerns. Later in the shift the patient complained of abdominal pain so she stopped the tube feeding and notified the physician. RN D confirmed she gave the patient 235 cc of tube feeding and 60 ml of water during her 12 hour shift beginning on 3/24/19 at 6:30 PM. The nurse stated she did not put in an order to stop the tube feeding but did pass it on to the day shift. Tests were ordered in the morning by the day physician team to determine placement of the PEG. The nurse said she checked for residual (aspirating the PEG tube to assess for contents in the stomach) at the beginning of the shift and did it again before giving med's and flush (documented at 8:00 PM). The nurse stated she felt the tube feeding was infusing appropriately by the infusion pump because it did not alarm.

E. Observations on 5/14/19 from 1:30 PM to 3:05 PM of 105 patients whose last fall assessment identified them as having a fall risk score of 46 or higher revealed 16 patients failed to have high risk fall interventions in place. Nursing Units who had patients without the bed or chair alarm activated included 2 patients on Trauma ICU, 2 patients on 2 North Medical Surgical Unit, 3 on HVI (Heart Vascular Institute) Unit and 4 on 4th floor. 2 Patients on HVI failed to have fall risk identification bracelets on. 4 patients on 4th floor failed to have on yellow anti slip socks. Note 1 patient on 4th floor did not have an alarm activated and did not have the yellow socks on. During tour on 5/14/19 at 1:50 PM on the Trauma ICU unit one of the non sampled patients was observed in bed without the fall alarm activated. The fall score was high at 50 per facility documentation. Interview with the RN F assigned to the patient stated "I repositioned him and forgot to turn the alarm back on."."

F. Review of facility policy titled "Fall and Risk for Injury Interventions" last revised 5/17 notes High Risk for Fall Prevention Plan Interventions for patients with a Morse Fall Score of 46 or higher include "Colored (yellow) arm band, colored (yellow) non -skid socks; when assistance needed use a gait belt; For patients who are confused, impulsive, or cannot teach back fall prevention instructions, recommend the following: Bed and chair alarms, scheduled toileting, remain with patient at arms length and in sight while toileting; Floor pad as needed ; Evaluate need for low bed; Campus-specific fall signage outside the door of room; Fall indicator signage inside room and visible to patient; Consult Physical Therapy, Occupational therapy, if warranted; Evaluate need for assessing orthostatic blood pressure ;Evaluate need for medication review.
For patients at High Risk for Injury the "ABCS"assessment tool is used. The tool was last revised 2/18. The assessment tool notes that "if any of the boxes are checked the patient is considered a high risk for injury from falls. A - Age 85 years or greater;
B - Bones: History of fractures, certain diagnoses, treatments or medications that cause bones to become weak; C - Coagulation: History of Cancer, blood thinners, coagulopathy or renal dialysis. Examples are blood thinners Coumadin, Plavix, Heparin, Lovenox, Eliquis; S - Surgical post op within 72 hours of surgery.

G. Record review of the Quality Assurance fall dashboard data for 11/2018 to 5/2019 shows the highest number of falls are on the HVI. Number of falls peaked in March 2019 at 34. April had 31 falls and as of 5/13/19 there had been 14 falls. Disabled alarms were a contributing factor for 6 falls.