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Based on staff interviews, observations, review of policy and procedures, and medical record review, the facility failed to ensure care was provided in a safe setting.

Findings include:

In the course of the clinical record review for Patient #5, the surveyor noted the patient was admitted on 9/27/10 from the Emergency Department (ED) with a diagnosis of "chest wall pain, dehydration." The patient's chief complaint was "Rib pain" and the ED report mentioned this was the fourth ED visit following a fall the patient sustained "about a week ago." According to the ED physician, Patient #5's son was concerned about his father and "wonders whether or not he might need to go in a nursing home." The physician documented Patient #5 would need to be admitted to the hospital for a three-day stay prior to nursing home placement and Patient #5 agreed to that hospital admission. Admission orders included the patient to be out of bed with assistance only. Along with various other admission orders such as lab work, radiology/imaging studies, physical therapy and medications, the physician included orders for "CIWA protocol." (CIWA refers to Clinical Institute Withdrawal Assessment tool. This clinical tool is used to assess 10 common signs of alcohol withdrawal. The 10 common signs include: nausea and vomiting, tremors, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headache, orientation/clouding of sensorium). The facility's protocol for treatment related to CIWA scoring was included with admission orders.

The facility's "Patients At Risk For a Fall Injury" policy and procedure reviewed on November 3, 2010, indicated all inpatients are assessed for falls risk upon admission. The policy stated that although facility personnel were responsible for ongoing assessments and taking appropriate action for patients 'at risk,' a documented reassessment was targeted for 1800 daily. According to Patient #5's clinical record, he was placed on falls risk patient safety interventions upon admission. These interventions included: Fall safety brochure given to patient/family, non-slip footwear, arm band - falls risk, bed alarm/motion detector pad. These falls risk patient safety assessments and interventions were noted in Patient #5's clinical record each evening during this admission.

During clinical record review it was noted Patient #5 was found on the floor, unresponsive at 23:30 on 9/29/10. The rapid response team was called and Patient #5 was placed in a c (cervical) collar and back board before being transported for imaging studies. The impression from the head scan indicated an intracranial hemorrhage that the physician described as a subacute left subdural with no mass shift. The night shift registered nurse (RN#2) assigned to Patient #5, noted one hour after the fall, the patient was extremely agitated and pulling at the c collar, intravenous fluid tubing, oxygen tubing and attempting to get out of bed. The patient was oriented to self but unable to follow commands and "pupillary response wnl (within normal limits)." RN #2 wrote that staff was sitting in room with patient for safety.

RN #2's next chart annotation at 12:45 a.m. on 9/30/10 indicated the patient continued to be agitated, pulling at equipment, attempting to get out of bed and the physician was called for orders. At 1:30 a.m. RN #2 wrote she noted a change in the patient's respiration pattern with aginal breathing, labored, with use of abdominal muscles. Also noted was a decrease in pupillary response along with injuries to the patient's left hip. Physician orders were obtained and Patient #5 was transported to radiology for a repeat head scan and Xray of left hip. The imaging report's impression of the repeat head scan was significant interval worsening in intracranial hemorrhage and was described by the physician as a massive intracranial hemorrhage on the left with significant mass effect as compared to the earlier head scan. Following imaging studies, the patient was transferred to ED for intubation (the placement of a breathing tube to assist with respirations). A neurosurgeon was consulted and notified Patient #5's family of the latest imaging results. Following the neurosurgeon's discussion with the family, the patient was made a DNR/DNI (Do Not Resuscitate/Do Not Intubate) therefore the patient was extubated (removal of breathing tube) and transferred to a private room on the floor. At 5:00 a.m. on 9/30/10 RN #2's chart annotation read the patient was found to have no respirations and no heart rate with the time of death noted by two nurses. The house supervisor and physician were notified and the physician was to notify the family of the patient's death. A review of the physician's discharge summary noted the first discharge diagnosis as "Massive intracranial hemorrhage following fall, on Plavix" and noted the Disposition at Discharge as "Deceased."

RN #1, the nurse assigned to Patient #5 on the evening shift of 9/29/10, was interviewed on 11/3/10. She easily remembered Patient #5 and recalled the day-shift nurse reported his confusion had gotten worse throughout the day on 9/29/10. RN #1 stated Patient #5 had attempted to climb out of bed once during her shift but the bed alarm sounded and she responded. She was able to reorient him and although he return demonstrated how to use the call bell, she realized he had limited short-term memory. RN #1 recalled that at 10:30 p.m. on 9/29/10, she had assisted Patient #5 to the bathroom and after helping him back to bed, she verified his bed alarm was activated. She checked on him again at 11:20 p.m., recalled hearing him snoring but did not look at the bed alarm. The nurse stated that after she had given report on the evening of 9/29/10, but before the night shift nurse (RN#2) had been able to take over care, Patient #5's roommate had called to inform the staff that Patient #5 was out of bed. The nurse stated she had been right outside Patient #5's door because she had another patient across the hall, and that Patient #5's bed alarm had not gone off but she heard the roommate's call and when she arrived in the room, Patient #5 was in the floor at the bathroom door and not responsive. She stated several other employees arrived quickly, including RN#2 (the oncoming night-shift nurse). A rapid response was called and rapid response team (RRT) arrived quickly. The RRT, which included a physician, stabilized Patient #5's head and applied light pressure to the patient's head to stop bleeding. She stated they applied a rigid cervical collar and backboard, placed the patient on a stretcher and transported the patient for imaging studies. She remained with Patient #5 and RN#2 until approximately 1 a.m. and noted that the patient became combative after returning to the room from radiology. She said the staff was having to hold him down and that since he was still agitated, the charge nurse assigned one of the floor's CNA's (certified nursing assistant) to remain with Patient #5 "100% of the time." RN #1 stated that when she left, Patient #5 did not have restraints on and an employee was sitting next to Patient #5. When asked if she knew why the bed alarm had not sounded when Patient #5 got up, RN #1 said it was later determined the bed alarm had been disabled, but she did not know who had disabled it. The nurse stated sometimes even patients learn how to disable alarms by watching care givers, but she had no way of knowing exactly how the alarm got turned off that evening.

On Thursday 11/3/10, RN #2 was interviewed. She stated she had taken care of Patient #5 both the night of his fall and the night before. She noted that although he was forgetful, he was "easily reoriented" however couldn't remember to use his call bell because he had difficulty with his short-term memory. On 9/29/10 at approximately 23:30, she recalled a rapid response team being called for a patient fall while she was receiving report for her shift. She stated when she arrived in Patient #5's semi-private room, the patient was half in and half out of the bathroom, he was unresponsive and there was lots of blood. She said the patient's head was stabilized and he was taken for imaging studies following application of a cervical collar and placement on back board. RN #2 recalled that after the imaging studies were completed, upon return to his room, he became "highly agitated, very impulsive, like closed head injuries." After having the charge nurse assign a staff member to stay with Patient #5 continuously, she notified the physician and obtained an order for restraints. RN #2 stated that when she returned to the room after obtaining the restraints and doing the paperwork related to restraint use, she found the patient calm and sleeping with the aide at his bedside and therefore did not apply the restraints. She noticed the patient had been incontinent and while changing his bed linens and clothing, she not only noticed a worsening bruise on his left hip, but also a change in his pupillary response and rousability. After notifying the physician, the patient was transported for more imaging studies. The physician was present in radiology and consulted with the neurosurgeon. With Patient #5's neurological status declining, the patient was intubated and while RN#2 was preparing to transport the patient to the Intensive Care Unit, the neurosurgeon consulted Patient #5's family with the results from the latest head scan. Patient #5 was then made a DNR. The patient was extubated and transported to a private room where he passed away at 5 a.m. RN#2 clarified that restraints were never applied to Patient #5.

The surveyor accompanied by the facility's Process Improvement Director and the Unit Manager of the floor where Patient #5 had fallen, toured a semi-private room identical to Patient #5's room. The patient had occupied bed "B" when he fell on 9/29/10. The bathroom was located between the door to the hall and the first bed (bed "A"). The second bed in the room (bed "B") was farthest from the bathroom, under the window. To estimate how far Patient #5 walked before falling, this surveyor walked from the side of bed "B" to the bathroom and estimated it to be 10 to 12 steps, having to negotiate around the foot of bed "A." The process improvement director verified Patient #5 had been in a bed like one of the beds in the room the surveyor was observing. The bed, in low position, was approximately 22 inches from the floor and was not equipped with a permanent bed alarm therefore making it necessary to apply a bed monitor under the sheets with the alarm connected to the bed's call button.

The facility's Compliance Officer and Risk Manager were interviewed on 11/4/10. They acknowledged Patient #5 had not had a sitter (someone who sits with a patient one-on-one) until after the patient had fallen.