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Based on record review and interview the hospital failed to ensure the Fall Risk policy was in place for 1 (#3) of 5 (#1-#5) patients as evidenced by patient #3 falling out of bed and being found on the floor with no bed alarm activation. Findings:

Review of a hospital policy titled "Fall Prevention", policy number 6.14, effective 06/94, last revised 1/11, presented as current hospital policy read in part: "Expected Outcome: 1. Patients at risk for falls are identified upon admission. 2. Patients are reassessed for the risk of falls during their hospital stay, and as needed for changes...2. When 4 or more risk factors are identified on the "Fall Risk Assessment" form, the patient is considered a High Fall Risk. The patient will have the high fall risk interventions added to the Nursing Plan of Care. The interventions to be initiated for a High Risk patient are: a. Keep call light within easy reach. b. Remind patient to call for help when getting up. c. Assist patients to get up and while up. d. Keep any obstacles off floor. e. Keep bed in lowest position...h. Patient/family will be educated on fall prevention. i. Nurse/CNA will make hourly rounds on patients. j. The bed alarm will be obtained from unit specific area and properly applied to the patient...3. When a patient is identified as a Fall Risk or a High Risk, a yellow armband will be placed on the patient's arm. 4. When identified as a risk for falls, a Nursing Diagnosis of "protocol, Fall Prevention" will be incorporated into the patient's plan of care. A sign with the intervention is placed in each patient's room...6. If a fall occurs, **** occurrence report will be completed. The occurrence report will note any medications that may have contributed to the fall..."

Review of a report titled "Risk Management Report - Patient" documented by S4RN revealed in part: "...Patient ID: (patient #3)...Event Code: FALLBD. Fall from Bed/Crib...Position of bedrails: Up. Position of Bed: Low. Was patient attended at time of fall? N (no)...Event Date: 02/09/13. Time: 0300...Exact Location: Pt. Room 108...Event Severity: No Apparent Injury...Possible Patient Factor: Confused/Disoriented...Supervisor Notified: Y (yes). (S5RN). Date: 02/09/13. Time: 0730. Pt./Family Notified: (name of patient #3 family member). Date: 02/09/13. Time: 0739. Method of Notification: Phone Call. Notified By: (S4RN). Physician Contacted: Y. Name: (S10MD). Date: 02/09/13. Time: 0720. Pre event condition, if known: Confused/Disoriented. Post event condition, if known: Confused/Disoriented...Witnesses:..Reported By: (S8CNA). Type of Treatment: Pt. assessed thoroughly. No bruises. No pain. Dr. (S10MD) ordered xray's. Description of Event/Comments:..Pt. found on floor near bed by nursing assistant (S8). Pt. was assessed. No bruising or markings noted. No c/o (complaint of) pain. Pt. helped back into bed by staff X3...Reviewing Manager's Comments...Other Manager Notes:..Unwitnessed fall. Patient found on floor. X-Rays done. No Fx's (fractures). No complaint of pain. No apparent inj (injuries). Pt. seen per (S10MD)...Reportable Agencies/Final Disposition...unresolved..."

Review of a report titled "Risk Management Report - Patient" documented by S5RN, House Supervisor, revealed in part: "...Patient ID: (patient #3)...Event Code: Other. If Other event code, explain: Family members irate about pt. falling out of bed. Event Date: 02/09/13. Time: 0338...Exact Location: Room 108...Event Severity: No Apparent Injury. Possible Cause: Other. Comment: Family irate and had numerous questions regarding rounding policy, bed rails, bed alarm policies. (S10MD) and myself (S5RN) unable to console in any way. They wanted to speak with UD (unit director) or Medical Director in person. Staff called and informed of them of family's wishes. Follow Up: Supervisor Notified: (S1Prog Dir.). Date: 02/09/13. Time: 0900. (S2Nurse Mgr.). Date: 02/09/13. Time: 0900. Physician Contacted: (S10MD). Date: 02/09/13. Time: 0730...Type of Treatment: Pt. sent for x-ray and CT (computed tomography scan of head)..."

Review of a handwritten account of the fall of patient #3, dated 02/14/13 by S8 revealed: "On Friday February 8, 2013 I came into work on my shift, received my assignment and made my rounds as I would routinely do. After my rounds was made, the Charge Nurse, (S4RN) informed me to keep a close eye on (patient #3) in room 108. I made note of it and made my rounds every 2 hours as I normally do and I checked on (patient #3) more frequently (every 20 to 30 minutes).When I checked on (patient #3) she was very confused. She would pull her diaper off and throw it on the side of the bed and I would replace each diaper that was pulled off with a fresh new diaper. She constantly messed with her call light, pressed the buttons on the outside of the rails well as the inside of the rail. Every time I saw this I addressed it to (patient #3) to not mess with the buttons on the bed because they were there for her own safety and I did not want her to hurt herself. I also made sure with every visit not only with her but with all my patients that there bed alarms are on and with her I definitely made sure of it as frequently I was in her room and her side rails were up to try to keep her from swinging her legs out the bed. Around 2:45 am (patient #3) call light went off. I was already sitting out at the nursing station. I immediately got up went in her room and saw her diaper was off on the floor, legs over the side rail. I put her legs back in the bed, I put a fresh new diaper on her as I did all night to make sure she was fresh and clean and comfortable, after this was all done I put her side rails up on her bed and bed alarm back on. I walked across the hall to another patient's room who had pressed the call light. I can not really how low long I was in the patients room but it was a while and once I was done caring for him I walked out of his room and saw (patient #3) on the floor. I immediately went to get help from (S4RN) and (S7LPN) on duty so that we can get (patient #3) off the floor. When I saw her on the floor she was still hooked up to her IV fluids and I noticed what I would call fluids from the IV fluids on the floor, I would not say it was urine on the floor because it did not have a yellow tint to be urine to me. Once we got her in the bed she was checked for bruises, and (S4RN) the Charge Nurse did a full assessment on her and told me that her vital signs were stable. After the assessment I gave her a bed bath, I put her clothes on and I got assistance from (S4RN) to help me put her in the wheelchair. I put the green alarm in her wheelchair seat for safety precaution just in case she attempted to get up out the wheelchair I would know. I put hers legs on the chair rolled her up to the nurses' station and locked her wheels and (patient #3) stayed with me the remaining of my shift." The statement is signed by S8CNA with a date of 02/14/13.

In an interview on 03/14/13 at 1:50 p.m. S3RN she stated patient #3 was in a wheelchair upon her arrival around 7:00 a.m. She further stated the only information she was given in report was that patient #3 had fallen during the night and there was no obvious signs of injury. S3RN stated she was told that S8CNA was in room, left briefly to care for another patient then patient #3 was found on floor when CNA came out of other room. S3RN stated the family arrived and were very upset about the patient having a fall. S3RN stated the family wanted to talk to the night shift nurse but she was already gone. S3RN further stated that family of patient #3 was demanding to "speak to someone". S3RN stated she called S5House Supervisor, and S10MD was at the hospital speaking with family shortly after. She further stated that the family was still angry but were not yelling and were still requesting to speak to a manager. S3RN stated she called S1Program Dir. at 9:35 a.m. to inform her of situation as it was a Saturday. S3RN stated that S1Program Dir. instructed her to provide the family with her voicemail number.

Review of a handwritten document from S4RN revealed: "At 0120, I went into (patient #3's) room at this time she was resting I bed with eyes closed. I made sure her bed was in the lowest position, side rails up x2, call bell in reach, and bed alarm on. Patient's door remained open all night do that staff could have easy visual access to her. At about 0210, I was in patient 109's room rechecking her blood sugar per MD orders. While coming from 109's room I peeped in on (patient #3) and she was still in her bed. After giving 109 medicine, I peeped in on (patient #3) again and she was in her bed. After that I was charting in the nurse's station. At about 0156 I administered pain medicine to another patient in 118. After that I went in nurse's station to chart. Shortly after 0300 (S8CNA) told me she found (patient #3) on the floor by her bed. I assessed patient she had no injuries or bruises. I checked her vitals and they were stable @ 114/66 HR (heart rate) 75 Respirations 16. Patient didn't voice any complaints of pain. Patient was confused and had expressive aphasia as before the fall. Patient's diaper was off and there was urine on the floor. I disconnected her from her IV fluids, her IV was dry and intact. (S8), (S7LPN) and I assisted (patient #3) back into bed. While (S8) bathed the patient I checked the patient's skin for any bruises, tears, or injuries. None noted. (S8) placed chair alarm in wheelchair and I helped her get patient in wheelchair. (Patient #3) was wheeled up to the Nurse's station for the rest of the shift where she was under direct supervision. I went into the Nurse's station to chart events. I later called (S10MD) who was on call and he gave orders. I made rounds on my other patients while (S8) watched (patient #3). I tried calling patient's husband, but the call wouldn't go through. I end up talking to (family member). I made her aware of patient's fall, patient's status, and that (S10MD) had given orders for xray. I continued charting and did incident report in computer. Refer to incident report for approximate times. "

In an interview on 03/13/13 at 2:00 p.m. with S7LPN she stated she became involved with patient #3 when CNA went in room and came out saying pt. was on floor beside bed. Pt. position - don't remember. S8CNA, S4RN, and S7LPN lifted pt. to bed. S4RN assessed pt. after being put in bed. S7LPN did not witness entire (full) assessment. S7LPN stated she was in med room and states she should have been able to hear bed alarm from there. S7LPN states she did not hear bed alarm and may not have been asked if bed alarm sounded when pt. fell during hospital investigation. Re: morning interaction with family. Son came to nursing station. Stated he wanted to know which nurse had his mother the night before. S7LPN explained to son that night nurse was gone and she went get S3RN. Daughter showed up about that time and S10MD was present and S5RN, House Supervisor, was also at LRC. Family was very upset that pt. had fallen and family thought pt. was on floor a long time. S7LPN stated she was unsure why family thought pt. was on floor a long time. S7LPN states pt. probably on floor less than 5 min due to activity by S8CNA and ongoing activity on floor. S7LPN stated the IV was disconnected when pt. was on floor. S7LPN estimated the amount of fluid on the floor was approximately 5 tiles wet in a circle. S7LPN stated the assessment on floor was quick "look" and a better assessment done in bed. S8CNA informed S7LPN that pt. was bathed, dressed, and was brought to nurse's station in wheelchair. S7LPN stated patient #3 was awake. Pt. was on a wheelchair alarm. S7LPN confirmed that the IV fluids were not reconnected prior to shift change at 0730. S7LPN stated she did not have much interaction with family. S7LPN stated that S4RN notified family but unsure of time. S10MD was notified at 6 or 6:30 am but not really sure. S4RN did speak to family (daughter) via telephone prior to leaving. S7LPN stated that the family was very upset, wanting House Supervisor, Management ...just upset. S7LPN stated she was never asked to fill out a written statement.

In an interview on 03/13/13 at 3:13 p.m. with S4RN she stated she was in the room of patient #3 at 1:20 a.m.. She documented. pt. asleep. S4RN stated she was in room 109 a lot due to cbg (capillary blood glucose) checks ordered every 2 hour. S4RN stated she could see into room 108 every time she went by. S4RN stated that at 0338 S8CNA advised S4RN that patient #3 was on the floor. S8CNA, S7LPN, and S4RN entered the room. Pt. #3 was on floor. S4RN stated patient #3's head was at HOB (head of bed) and she was "kind of on her side facing bed." S4RN stated she assessed patient #3 for bleeding on floor. S4RN stated she disconnected the IV fluids from patient #3. She further stated that there was fluid on floor. S4RNstated patient #3 was put back in bed and she did a visual assessment. "I looked over pt. while S8CNA cleaned her up." S4RN confirmed pt. #3 was placed in wheelchair and brought to nurse's station. S4RN stated S10MD was notified between 6:30 -7: 00 a.m. S4RN stated that S10MD should have been called immediately after pt. #3 fell and that the family should have been notified immediately. S4RN stated she spoke to pt. #3's daughter at 7:39 a.m. S4RN stated she gave report to S3RN and she could see an elderly man at nursing station but had no interaction with family.

In an interview on 03/14/13 at 12:30 with S1 Program Director, and S2Nurse Mgr., S2 Nursing Mgr. stated she obtained written statements from S8CNA and S4RN. S2Nurse Mgr. could offer no explanation of the differences between her documentation on the Service Recovery Form of a verbal interview with S8CNA that the bed alarm was off and the handwritten incident report by S8CNA indicating it was on. Both S1Program Dir. and S2Nurse Mgr. confirmed there should be medication variance report for no IV fluids from fall at 0338 to 0730 on 02/09/13. Both stated that the cause of the bed alarm not sounding when patient #3 exited the bed was due to an "Unknown cause - bed alarm off or bed alarm malfunctioned." Family of patient #3 refused to speak to S2Nurse Mgr. on the telephone on the morning of 02/09/13 as she was not in the office yet. S1Program Dir. stated she spoke to family of patient #3 but has no documentation of call. S1Program Dir. stated she did meet with the family of patient #3 on 02/13/13 and she was aware she did not have the results of the investigation but felt that putting them off would upset the family further. S1Program Dir. stated that at least she would know what information they wanted. S1Program Dir. stated the family basically had 2 questions: What time did pt. fall?, and what was being done about her elevated BUN? S1Prog Mgr. stated that S9MD had given orders for fluids to treat the dehydration/elevated BUN. Patient #3's family requested the medical record but was told to a he could obtain medical record from Medical Records Dept. Nurse Mgr. "is not aware of pts. cognitive status." S1Program Dir. and S2Nurse met with family of patient #3 on 2/14/13 both stated they had the same questions. When did she fall and how long before she was found. The family was given time of fall of 0338 and approximate time on floor being less than 15 minutes per CNA.

In an interview on 03/13/13 at 2:30 p.m. with S8CNA she stated she remembers patient #3. S8CNA stated she was in patient #3's room and changed patient. S8CNA stated she did turn bed alarm off when providing care to patient #3. She then went into Room 107 across hall and was in room 107 15 minutes or less. When exiting room 107 could see patient in 108 (#3) on floor. S8CNA stated she called for help and S4RN and S7LPN came to help. The three staff members immediately got pt. #3 on the bed. S7LPN asked pt. if she was ok. S4RN left to go get blood pressure machine. S8CNA looked pt. over from head to toe. S8CNA bathed, changed pt. and put her in a wheelchair. S8CNA stated the "IV was connected, I think. That is not what I do." S8CNA stated there was no assessment of patient #3 done on the floor. S8CNA confirmed there was no bed alarm sounding from 108 when she noticed patient #3 on the floor. S8CNA cannot recall if alarm was on or off. S8CNA confirmed the hospital policy says it should be on. S8CNA reviewed the statement documented by S2Nurse Mgr. and agrees with statement that alarm was off. S8CNA stated she was not here at 7:30 a.m. when family arrived. (CNA's get off at 6 am)

Based on record review and interview the hospital failed to ensure the Registered Nurse administered drugs and biologicals in accordance with the orders of the physician responsible for the care of the patient as evidenced by 1 (#3) of 5 (#1-#5) patients not receiving the intravenous (IV) fluids for 3 hours and 54 minutes on 02/09/13. Findings:


Review of the Grievance documentation revealed the following: "02/12/13 (1530) (S12QA)...Title (Patient #3)...Date of Complaint: 02/09/13...Grievance: Y...(document lists name of complainant and relationship to patient)...Type of Concern: Physical comfort and Service Delivery...Title: (S2Nurse Mgr.)...Received service recovery form from (S2Nurse Mgr.): Pt. (patient #3) in Rehab and fell on the floor...Questions related to time of patient fall, rounding by staff, and patient's abnormal BUN (blood urea nitrogen) lab value...Spoke with (S10MD) per phone. Patients BUN of 44 was reported to him on 2/6/13 by (S6RN). Order was noted to consult (S9MD) for medical management. (S10MD) says he did not have a baseline at that time for patient's BUN. He consulted (S9MD) for medical management and felt that fluids should be encouraged and labs should be drawn again in a couple of days. (S9MD) ordered a re-check CP7 (metabolic panel). Patient's BUN had increased to 60. IV (intravenous) fluids were ordered per (S9MD)..."

Review of a handwritten document from S4RN revealed: "...Shortly after 0300 (S8CNA) told me she found (patient #3) on the floor by her bed...I disconnected her from her IV fluids, her IV was dry and intact. (S8), (S7LPN) and I assisted (patient #3) back into bed....(S8) placed chair alarm in wheelchair and I helped her get patient in wheelchair. (Patient #3) was wheeled up to the nurse's station for the rest of the shift where she was under direct supervision..."

Review of a document titled "Patient: (patient #3) Timeline of Incident", created by (S2Nurse Mgr.) on 02/14/13 revealed the following:

02/08/13
? 0845 - (S9MD) rounded on patient on 02/08/13. Ordered a repeat CP7. BUN had increased to 60. IV fluids were ordered per (S9MD). IV fluids infusing by (S3RN) at 1230
02/09/13
? 0700 - Documentation noted per (S4RN) that fluids were infusing at 1920 on 02/08/13
? 0022 - IV fluids documented infusing 2/9/13
? (S8CNA) reported she rounded on patient within 15 mins of patient found on floor at 0338. Patient had taken attends off and threw it on the side of the bed. IV fluids were still infusing. Fluid noted on floor. CNA reported not yellow tinged. Possibly urine or IV fluids. Pt. denied any pain...IV fluids not infusing at this time...
? 0730 - Patient received by (S3RN). IV was reconnected and fluids restarted infusing

In an interview on 03/13/13 at 2:00 p.m. with S7LPN she stated the IV was disconnected when pt. was on floor. S7LPN estimated the amount of fluid on the floor was approximately 5 tiles wet in a circle. S7LPN stated the assessment on floor was quick "look" and a better assessment done in bed. S8CNA informed S7LPN that pt. was bathed, dressed, and was brought to nurse's station in wheelchair. S7LPN confirmed that the IV fluids were not reconnected prior to shift change at 0730.

In an interview on 03/13/13 at 3:13 p.m. with S4RN she stated that at 0338 S8CNA advised S4RN that patient #3 was on the floor. S8CNA, S7LPN, and S4RN entered the room. S4RN stated she disconnected the IV fluids from patient #3. She further stated that there was fluid on floor.

In a telephone interview on 03/14/13 at 11:12 a.m. with S10MD he stated he was aware of patient #3's BUN/Cr being elevated on 02/06/13. He stated he ordered consultation to S9MD. Once consulted medical MD takes care of fluids. S10MD stated he ordered force fluids. He stated he wanted to try po fluids first. S10MD also stated he was contacted about UTI (urinary tract infection) and he started antibiotics on patient #3, being careful not to use an antibiotic that would further impair renal function. S10MD confirmed S6RN advised him about the BUN/Cr. On 02/06/13 and that is when he ordered the consult for S9MD. S10MD stated when he returned on 02/09 the IV fluids were started.

In an interview on 03/14/13 at 12:30 with S1Program Director, and S2Nurse Mgr. Both confirmed there should be a medication variance report for no IV fluids from fall at 0338 to 0730 on 02/09/13.

In an interview on 03/14/13 at 1:50 p.m. S3RN she confirmed that at 0730 on 02/09/13 that patient #3's IVF's not running. She stated she flushed line and put fluids back on. S3RN stated she did discuss with the family that pt. was dehydrated on 2/8/13. She further stated that she discussed labs with S10MD on 02/08/13 and pt.'s mental status being drowsy. S10MD ordered IVF's to treat the dehydration and Cipro IV to treat the UTI.