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Based on observation, document review, record review, and interview, the facility failed to ensure the nursing staff implemented the falls prevention policy and failed to implement the procedure for patient and/or family complaints. The nursing staff did not document all fall prevention measures were in place for four of six patients (Patient (P)1, P4, P5 and P6) with fall risk scores greater than six and nursing did not complete a fall investigation for three of three patients (P1, P2, P3) following a fall. The facility did not document a complaint report and investigation for one of two patients (P1) and failed to provide a written response within 30 days to the patient or family member for two of two patient complaints (P1, P11). Failure to implement and follow policy and procedure has the potential to place patients at risk for harm and unresolved concerns and complaints.


Findings Include:


1. Review of a facility's policy titled, "Fall Prevention" dated 02/20 revealed, "Upon admission, the patient will be assessed by the RN [Registered Nurse] for potential/actual fall risk ... The patient will be reassessed every shift ...Normal/Low Risk (0-3 points) ... Keep call light within reach ... Bed in low position with brakes locked ... document side rails up or down ... Non-slip footwear. Assist if needed ...Moderate Risk (4-6 points) ... Interventions listed above ... Assistance with elimination ... Check elimination needs every two hours while awake ... yellow star on door ... Educate patient/significant other regarding Fall Risk interventions ... Place a yellow fall risk bracelet on the same arm as the patient's ID bracelet ... High Risk (> [greater than] 6 points) ...Interventions listed above ...Check elimination needs every two hours while awake ... Hang a yellow star on the door of the patient's room indicating that the patient is a "fall risk." ... Activate electronic bed/chair alarm ... Instruct patient to call for assistance ... Reorient patient to environment as indicated ... Provide patient with yellow fall prevention slipper socks ... Provide the patient with yellow fall prevention blanket that shall remain visible at all times ... If the patient should fall: ... Complete an incident report and a fall assessment and investigation form."


Patient 1

Review of P1"Discharge Summary" dated 10/25/20 showed P 1 was admitted for COVID-19 on 10/22/20. The document showed P1 became confused and disoriented during the hospital stay. The summary showed a bed alarm was in place, the patient fell, and fractured the "left femoral neck [upper portion of the femur]." P1 was transferred to another hospital for surgery.

Review of the "Physical Assessment" section of the "Progress Notes" dated 10/24/20 showed P1 had become confused, agitated, and disoriented with "hallucinations, reports seeing trails on floor and a person in a wheelchair." Further documentation on 10/24/20 showed P1 "attempted to crawl out of wheelchair" and cut the intravenous (IV) line with a pocketknife which P1 refused to give to staff. On 10/25/20, documentation showed P1 is restless, confused, agitated, and attempted to pull out the IV. Ativan (medication used for anxiety) 0.5 milligrams (mg) IV push (medication is pushed into the bloodstream with a syringe) was given on 10/24/20 at 12:21 PM, 6:12 PM and 10:12 PM. Ativan was given again on 10/25/20 at 6:29 AM.

Review of the "Fall Risk Score" documented in the printed "Physical Assessment" section of the "Patient Progress Notes" dated 10/22/20 through 10/25/20 showed the following scores:

10/22/20 initial assessment = score of "1."
10/23/20 at 8:24 AM = score of "5." All precautions in place per policy.
10/23/20 at 6:55 PM = score of "3." All precautions in place per policy.
10/24/20 at 7:02 AM = score of "6." All precautions in place per policy.
10/24/20 at 7:04 PM = score of "10." All precautions documented except yellow slip resistant socks and yellow star on door in place.
10/25/20 at 6:29 AM = score of "11." All precautions in place per policy

Review of "Fall Report" indicated P1 had been checked on 10/25/21 at 6:18 AM, 6:29 AM, 7:00 AM, and 8:00 AM and not again until being discovered on the floor by the physician at approximately 12:00 PM.

During an interview on 10/21/21 at 3:00 PM, the Physician stated P1 had not been checked at least every two hours as required. The physician stated that the bed alarm was not alarming when he entered the room and discovered the patient on the floor.

Review of the "Incident Summary Initial Investigation" showed the bed alarm did not alarm, but there was no investigation of the bed alarm to determine why it was not alarming when the physician entered the room. There was no identification of all factors potentially related to the fall such as mental status, medications, or lack of toileting every two hours.

There was no evidence a "Fall Assessment and Investigation" Form had been completed following the fall on 10/25/20.


Patient 2

Review of the electronic medical record (EMR) showed P2 had an admission date of 11/05/20, a discharge date of 01/08/21, and a diagnosis of a stroke with left-sided weakness. Documentation on 01/02/21 showed the patent was found by the Certified Nursing Assistant (CNA) on the floor. P2 was assessed by the RN and no injuries were found. Review of a "Fall Report" dated 01/03/21 indicated the patient attempted to walk from a chair back to the bed. The report indicated a call light was in reach but P2 had not called for assistance.

There was no evidence a "Fall Assessment and Investigation" Form had been completed following the fall.


Patient 3

Review of P3's "Fall Report" dated 04/28/21 showed the patient reported to the CNA that he had fallen in the bathroom, "woke up on the floor" and had crawled to the chair by the bed. No injuries were noted." The report does not include "Investigation Findings" or "Action Taken."

There was no evidence a "Fall Assessment and Investigation" Form had been completed following the fall.


Patient 4

Review of the printed "Physical Assessment" section of P4's"Progress Notes" revealed an admission date of 10/19/21 and discharge date of 10/21/21. On 10/20/21 at 7:48 PM the RN documented a "Fall Score" of "8". There was no documentation of a bed/chair alarm, yellow fall socks, yellow blanket, or star on the door per the "Fall Prevention" policy.


Patient 5

Review of the printed "Physical Assessment" section of P5's "Progress Notes revealed an admission date of 10/18/21 with a diagnosis of COVID-19. On 10/20/21 at 7:32 PM the "Fall Score" documented a score of "9." There was no documentation of a bed/chair alarm, yellow slip resistant socks, yellow blanket, or a yellow star on the door.


Patient 6

Review of the printed "Physical Assessment" section of P6's"Progress Notes" revealed an admission date of 10/18/21 and diagnosis of COVID-19. Review of "Fall Score" revealed the following:

10/18/21 at 5:17 PM = score of "11." There was no documentation of a bed/chair alarm, or a yellow star on door.
10/19/21 at 6:10 PM = score of "14." There was no documentation of a yellow star on door, yellow slip resistant socks, or a yellow blanket.
10/20/21 at 8:21 AM = score of "14." Documentation indicated there was a yellow star on the door.
10/20/21 at 7:15 PM = score of "9." There was no documentation of yellow star on door, yellow socks, or a bed/chair alarm.

Observation on 10/20/21 at 2:50 PM showed that there was not a yellow star on the door of P6's room.

During an interview at the time of the observation, RN4 confirmed there was not a yellow star on the door to indicate P6 was a fall risk. CNA2 was also present during the interview and stated P6 does have a bed and a chair alarm but was not wearing yellow slip resistant socks. CNA2 stated, "[P6] is sitting in a chair with his feet elevated and does not have socks on." RN4 confirmed P6 should have yellow socks on if sitting in a chair.

During an interview on 10/22/21 at 10:00 AM, the Unit Manager for the Medical Surgical unit confirmed that the yellow stars should have been on the doors on 10/20/21 for all current patients with a fall score greater than 6 and stated that he was not aware that any monitoring of staff for compliance with fall precautions has ever occurred. The Unit Manager also stated he/she was not aware of the "Fall Assessment and Investigation" form referred to in the "Fall Prevention" policy and has never completed this form.



2. Review of the hospital's policy titled, "Grievance/Complaints" dated 09/18 showed, " ... shall promptly resolve any grievance whether written or verbal ... For the purposes of this requirement, an email or fax is considered "written" ... All attempts to resolve the grievance/complaint within 7 days will be made and if the grievance is not or will not be completed within 7 days, the hospital shall inform the patient/resident's or the patient/resident's representative that the hospital is still working to resolve the grievance and that the hospital will follow up with a written response within a stated number of days."


Patient 1

Review of documents provided on 10/22/21 showed email exchanges between P1's daughter and the former CEO between 10/13/20 and 08/16/21. The emails showed P1's daughter requested information about whether an investigation had occurred involving the bed alarm in place on the day of P1's fall that did not alarm and the care P1 received while in the hospital.

There was no documentation that the emails resulted in a complaint/grievance investigation being initiated. There was no evidence of an "Incident Summary", or "Initial Investigation" conducted by the hospital's Risk Manager (RM).

There was no evidence that an attempt to resolve the grievance occurred within seven days or that written response was sent within 30 days detailing the steps taken to resolve the grievance.


Patient 11

Review of a complaint "Incident Summary" and "Initial Investigation" dated 12/10/20 revealed P11, a labor and delivery patient, complained to the nurse that another employee shared health information with the baby's father. The unit had been on lock down because P11 had stated she was fearful of the baby's father. Documentation showed the staff person was suspended pending the investigation, the complaint was investigated, conclusions were reached, recommended actions were included, and follow-up was identified.

There was no evidence that a written response was sent to P11 detailing the steps taken to resolve the grievance.

Based on policy review, observation, and interview, the facility failed to ensure all visitors and patients wore masks and were screened for signs and symptoms of COVID-19 upon entering the front door of the hospital. Failure to screen for signs and symptoms of COVID-19 or to ensure that all visitors and patients who entered the facility wore masks has the potential to spread COVID-19 virus which could impact all patients and staff in the hospital who are susceptible to COVID-19.


Findings Include:


Review of the hospital's policy titled, "Kearny County Hospital COVID-19 Screening and Prevention" dated 08/21 revealed, "All patients and visitors will ...complete screening at the entrance of the facility by a dedicated staff member and wear a mask. Anyone who does not pass screening will not be permitted in the building and will be instructed to call the Family Health Center ...2. Those who refuse to wear a mask (for non-medical reasons) will be asked to return to their vehicle and will not be permitted in the building. A tele-medicine visit will be offered."

Observation of the entrance to the hospital on 10/20/21 at 8:00 AM, revealed a table with a large sign behind it which read, "Please were a mask." There was no hospital staff standing at or near the table and on the table, was a standing temperature scanner. A sign on the table directed visitors and patients to the registration desk located to the left of the table. Observations on 10/20/21 revealed that screening or temperature checks of visitors or patients did not occur.

During an interview on 10/20/21 at 8:50 AM, the Chief Nursing Officer (CNO) stated that there had been a designated person at the table who would check for signs and symptoms of COVID-19 and ensure everyone who entered the hospital was wearing a mask "until recently when money ran out for that position." The CNO confirmed that at this time there was not a designated staff person who screens visitors and patients as they enter the hospital. The CNO also stated that a sign on the table directs visitors and patients who enter the hospital to the registration desk. The CNO confirmed that not all visitors and patients comply with this process.

During an interview on 10/20/21 at 9:15 AM, the Infection Control (IC) nurse stated screening of staff, patients, and visitors had been completed and documented until approximately three weeks ago and that all patients and visitors are supposed to stop at the registration desk to be screened.

Observation on 10/20/21 at 11:20 AM, Visitor 1 entered without a mask, walked past the registration desk and entered the medical unit. No hospital staff screened visitor 1 or asked visitor 1 to wear a mask.

Observation on 10/21/21 at 9:15 AM, showed Visitor 2 entered the hospital wearing a mask and carrying a small case. Visitor 2 walked past the registration desk and onto the medical unit. At the time of the observation, the registration desk staff was asked what should happen if a person walked past without being checked for signs and symptoms of COVID-19. He/she stated, "I would stop them." When informed that Visitor 2 just walked by and onto the medical unit, he/she stated, "They will know that I didn't ask the COVID-19 questions because the person will not have a sticker and they (the unit clerk at the desk on the medical unit) will ask them."

During an interview on 10/21/21 at 9:23 AM Visitor 2, who entered the hospital and was standing at the medical desk on the unit, confirmed that he/she had not been screened for signs or symptoms of COVID-19.

During an interview on 10/21/21 at 9:27 AM, the unit clerk on the medical unit, confirmed he/she had not screened Visitor 2 for signs or symptoms of COVID-19.