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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 §482.13 PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on observations, interviews and document review, the facility failed to ensure fall precautions were implemented for high fall risk patients in order to ensure a safe environment. Specifically, the facility failed to ensure bed alarms and chair alarms were activated in order to alert staff if patients were getting out of bed or the chair. The failure was identified in four of eight medical records reviewed for patients who experienced a fall and five observations of high fall risk patients on the medical surgical units. (Patients #1, #12, #13, #14 and Patients #4, #5, #6, #7, and #8).

Based on observations, interviews and document review, the facility failed to ensure fall precautions were implemented for high fall risk patients in order to ensure a safe environment. Specifically, the facility failed to ensure bed alarms and chair alarms were activated in order to alert staff if patients were getting out of bed or the chair. The failure was identified in four of eight medical records reviewed for patients who experienced a fall and five observations of high fall risk patients on the medical surgical units. (Patients #1, #12, #13, #14 and Patients #4, #5, #6, #7, and #8).

Findings include:

Facility policies:

The Fall Prevention and Intervention policy read, universal fall precautions are to be used with all patients, regardless of the fall risk score. All patients who are assessed and have a Fall Risk Score of 50 or greater, are to have the High Fall Risk Precautions and the Universal Fall Precautions implemented. According to facility Fall prevention policy, for High Fall Risk patients staff should initiate mandatory bed and chair alarms, keep commode or urinal at the bedside, keep the room door and privacy curtain open, stay with the patient while toileting, supervise all ambulation and transfers, relocate closer to nurses' station, increase rounding frequency, and/or use a 1:1 safety attendant/sitter.

The Patient Fall Prevention policy read, the purpose is to ensure that a plan that promotes fall prevention will be developed at admission and updated as indicated by the patient's condition. All patients will be identified for risk to fall at admission, every shift and as the patient's condition or mental status changes during the course of the shift. The individualized fall prevention plan must be developed for all fall risk individuals and documented on the plan of care.

References:

The facility reference, Determine if Patient is At-risk for Fall read, to determine if the patient is at risk for falling complete the Morse Fall Risk Scoring Tool on all patients. High risk has a score of 50 and greater. Morse Fall Risk Scoring Tool should be used at admission, every shift, and with change in patient's condition or mental status.

The Bedside Mobility Assessment Tool (BMAT) read, the tool is used to assess a patient's ability to move independently. BMAT has four levels, level one is the patient who requires the most assistance from staff for mobility and care. The patient who scores a four is independent with mobility and cares. The tool has numerous skills which are pass or fail. If any skill is failed in the level they are scored at that level.

1. The facility failed to ensure bed alarms and chair alarms were activated for all high fall risk patients in order to ensure a safe patient care environment.

A. Policy

According to facility policy, for high fall risk patients staff were to initiate mandatory bed and chair alarms, keep commode or urinal at the bedside, keep the room door and privacy curtain open, stay with the patient while toileting, supervise all ambulation and transfers, relocate the patient closer to nurses' station, increase rounding frequency and/or use a 1:1 safety attendant/sitter.

B. Medical Record Review

a. A review of Patient #1's medical record revealed the patient was admitted with a traumatic brain injury (TBI) and was impulsive. According to documentation entered on 5/2/21 at 11:45 a.m. the patient was on bed rest and considered immobile and had a BMAT level of two, which required a ceiling lift for transfers. At 4:43 p.m. on the same day, a nursing note revealed Patient #1 was found on the floor by her father. Patient #1's father alerted nursing staff that the patient had fallen.

i. The facility provided a patient safety event note related to Patient #1's fall. Review of the patient safety event note indicated the bed alarm was not on at the time the patient fell and a sitter had been requested but no staff was available.

b. A review of Patient#12's medical record revealed on 4/5/21 Patient #12 had a score of 75 on the Morse Fall Scale. A nursing note in the record entered on 4/5/21 at 9:54 a.m. read, the registered nurse (RN) responded to a low oxygen saturation level call and found the patient on the floor with the bed alarm off.

c. A review of Patient #13's medical record revealed on 1/15/21, the patient was post-operative day one and had an epidural catheter (a fine catheter inserted into a patient's spine to inject medications for local anesthesia and pain relief) and Foley catheter (a tube place in the bladder to drain urine) in place. On 1/15/21 at 7:12 p.m. a nursing note read, during shift change the patient fell out of bed. On assessment, the patient seemed confused about calling for assistance and her legs felt "heavy" so she attempted to roll out of bed. At the time of fall the bed alarm was not activated.

d. A review of Patient #14's medical record revealed the patient had a history of upper extremity weakness and numbness as well as gait issues. Patient #14 had a BMAT of 3, and according to facility policy recommended interventions included bed, chair, or commode alarms and supervised ambulation. On 4/6/21 at 8:26 p.m. Patient #14 had a score of 85 on the Morse Fall scale. On 4/7/21 at 6:53 a.m., Patient #14 had an unwitnessed fall in the bathroom. According to the medical record, a bed or chair alarm were not set at the time of Patient #14's fall.

C. Observations on the medical unit revealed patients at high risk for falls who did not have a bed or chair alarm activated.

a. On 06/16/21 at 2:53 p.m., an observation of the medical-surgical unit was conducted. Upon observation, Patient #4's bed alarm was turned off while the patient was in bed.

i. A review of Patient #4's medical record revealed on 6/16/21 at 11:04 a.m. the patient was deemed a high fall risk with a Morse score of 50.

b. On 06/16/21 at 2:54 p.m., observation revealed Patient #5's chair alarm was disconnected from the alarm machine while the patient was in the chair.

i. A review of Patient #5's medical record revealed the patient was deemed a high fall risk. On 6/16/21 at 12:46 p.m. the patient had a score of 70 on the Morse fall scale. Additionally, the patient required assistance from two staff members for mobility.

c. On 06/17/21 at 6:16 a.m., observation revealed Patient #6's bed alarm was turned off while the patient was in bed.

i. A review of Patient # 6's medical record revealed the provider placed a high fall risk order for the patient on 06/12/21 at 5:45 p.m. nursing note on 06/14/21 read, the patient was a high fall risk requiring a lift when transferring.

d. On 6/17/21 at 6:24 a.m., observation revealed Patient #7's bed alarm was turned off while the patient was in bed.

i. A review of Patient#7's medical record revealed on 06/16/21 at 10:51 p.m., Patient #7 had a score of 85 on the Morse fall scale, indicating the patient was a high fall risk.

e. On 06/17/21 at 6:35 a.m., Patient #8 was observed in bed with the bed alarm turned off.

i. A review of Patient #8's medical record revealed the patient had an exploratory laparotomy (a general surgical procedure in which the abdomen is opened and the organs examined for injury or disease) on 6/14/21, three days before the observation. Patient was placed on a lidocaine (an anesthetic medication used to relieve pain) drip on 6/15/21. Patient #8 was rated a 60 on the Morse fall scale on 6/16/21 at 11:32 p.m. On 6/17/21 at 3:28 a.m. a nurse's note was entered which read, the patient was a fall risk and fall precautions were in place. Additionally, the nurse noted Patient #8's call light was within reach and the bed alarm activated.

f. According to facility policy the observed high fall risk patients were to have a bed or chair alarm activated in order to prevent falls.

C. Interviews

a. On 06/16/21 at 3:24 p.m., an interview with Medical Surgical unit nurse (RN) #3 was conducted. RN #3 stated it was important to identify high fall risk patients and implement interventions to prevent patient injury. She stated interventions included implementing bed alarms, non-slip yellow socks, hallway yellow room light, updating white boards in patient's rooms, and assigning the correct zone on bed alarms. She stated these interventions helped staff to recognize the level of assistance a patient needed to prevent a fall. RN stated she was unaware of any action plan to reduce falls on the unit.

b. On 06/16/21 at 1:08 p.m., an interview with Medical Surgical unit nurse (RN) #4 was conducted. RN #4 stated patients with traumatic brain injury (TBI), dementia, confusion, delirium were determined to be at high fall risk. She stated fall precautions included moving patients closer to the nurses station, leaving doors open, and implementing bed and chair alarms. She stated these interventions were important because she could not be in a patient's room at all time.

RN #4 confirmed she was assigned to care for Patient #1. She stated Patient #1 had a TBI and was impulsive, and she stated a sitter had been requested for Patient #1 but was not provided.

This is in contrast with the facility's fall prevention and intervention policy, which read for high fall risk patients staff were to initiate mandatory bed and chair alarms and/or use a 1:1 safety attendant. According to Patient #1's medical record, neither intervention was in place at the time Patient #1 fell and was found on the floor by a family member.

c. On 06/17/21 at 12:54 p.m., an interview with the Director of Medical Surgical Unit (Director) #8 was conducted. Director #8 stated according to facility policy the Morse fall scale was used to determine if a patient was high fall risk. She stated staff were also to consider a patient's medications, history of falls, altered mental status (AMS), alcohol withdrawal, epidural use, post-surgical status and toileting needs to determine whether a patient was a high fall risk. She stated because the Morse fall risk scale did not account for all of these factors, staff were to also consider the use of different fall risk assessments to determine a patient's level of risk.

Director #8 stated it was important to identify high fall risk patients and activate bed alarms to prevent injuries to patients. Director #8 stated post-operative patients were at high fall risk and high fall risk interventions should be in place for patients who were post-operative.

Director #8's interview was in contrast to Patient #13's medical record, as the record revealed Patient #13's was post-operative day one but did not have a bed alarm activated on the day she fell. Her interview also conflicted with observations of patients on the inpatient units, and medical records reviewed for Patients #1, 12, 13 and 14, as the observations and records revealed patients who were at high risk for falls did not have bed and/or chair alarms activated in order to prevent injury to the patients.

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 document review and interviews, the facility failed to ensure nursing staff completed assessments as ordered by the provider. Additionally, the facility failed to ensure nursing staff assisted patients with activities of daily living (ADLS) in 3 of 14 Medical records reviewed (Patient #1, Patient #13, and Patient # 14).

Based on document review and interviews, the facility failed to ensure nursing staff assisted patients with activities of daily living (ADLS) in 3 of 14 Medical records reviewed (Patient #1, Patient #13, and Patient # 14).

Findings include:

Facility policies:

The facility nursing standards of care policy read, the patient receives appropriate hygiene and comfort measures based on his/her needs. All patients will receive daily hygiene which includes a shower or bed bath, oral care, and skin care. All care will be documented in the ADL Flowsheet. This can be delegated to a Certified Nursing Assistant (CNA). Daily shower, bed bath, linen change as needed or based on patient request must be documented.

The Assessment time frames by department/nursing unit policy read, Full head-to-toe physical
assessment minimum of every 12 hours. Skin Assessment every 12 hours. Pain as per policy.
Repeat risk assessments and make appropriate referrals upon change in condition.

The skin assessment and treatment policy read all inpatient and observation status patients are appropriately assessed and treated for skin, wound, and pressure injury risk and alteration upon admission and at regular intervals thereafter, according to licensed practitioner orders, and procedures described in this policy.

References:

The facility reference Braden scale for At Risk Patients read, interventions for at risk patients, manage moisture by the use of commercial moisture barrier, use absorbent pads or diapers that wick and hold moisture, offer bedpan/urinal and glass of water in conjunction with turning schedules.

1. The facility failed to ensure patient ADLs were completed as per facility policies.

A. Medical Records

a. A review of Patient #1's medical record revealed she was admitted on 4/20/21 for a traumatic brain injury (TBI) and was discharged on 5/3/21. Review of the nursing ADL flow sheets read Patient #1 received a bed bath on 4/22/21, 4/23/21 and 4/24/21. Additionally, Patient #1 had received a shower on 4/29/21. According to the flowsheet there was no documentation or rationale of the patient or the patient's family refusing a bed bath or shower.

b. A review of Patient #13's medical record revealed Patient #13 was admitted from 1/15/21 for rectal cancer treatment and was discharged on 1/19/21. Documentation on the nursing ADL flow sheets read, the patient had received a bed bath on 1/16/21 and 1/18/21. There was no documentation of the patient's refusal for a bed bath or shower on 1/15/21, 1/17/21 or 1/19/21.

c. A review of Patient #14's medical record revealed the patient was admitted on 4/6/21 for a cervical cord compression and was discharged on 4/11/21. Review of the nursing ADL flow sheets revealed the patient had not received a bed bath or shower during the hospital stay. On 4/9/21 at 10:26 a.m. per physician order read patient #14 may have a postoperative shower. Additionally, there was no documentation if or why the patient's refused a bed bath or shower during the patient's stay.

The lack of bed baths or showers offered to the patients noted above was in contrast to the facility policy which read that the patient receives appropriate hygiene and comfort measures based on his/her needs. All patients will receive daily hygiene which includes a shower or bed bath, oral care, and skin care.

B. Interviews

a. On 06/22/21 at 9:55 a.m., an interview with RN #6 was conducted. RN#6 stated RNs and CNAs were responsible to ensure ADLs were provided to patients. RN #6 stated that when a patient refused any ADLs, she would re-educate the importance of ADLs. If she was unable to change the patient's mind, RN #6 stated she would document in the patient's medical record the patient's refusal. Also stated, ADLs documentation provides assessment and monitors patients ' status and/or changes to the patient.

b. On 06/22/21 at 10:05 a.m., an interview with CNA #7. CNA #7 stated the CNAs were responsible for assisting the patients with bathing, toileting and ambulation. CNA #7 stated that if a patient refused a bed bath or shower, she would document the refusal in the ADL flowsheets of the patient's medical record. Also stated the importance of providing ADLs help patients feel better and could monitor patients' status.