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Based on review of hospital policy, observation, grievance log, medical records, physician, patient and staff interviews the hospital nursing staff failed to supervise and evaluate patient care by failing to implement measures to prevent a patient fall in 2 of 2 patients records reviewed (Patient #2 and Patient #4); and failed to turn and reposition a patient to prevent pressure injuries in 1 of 4 patient records reviewed. (Patient #1)

A. Review on 2/28/2023 of hospital policy titled Fall Prevention Program effective date 08/17/2021, revealed "PURPOSE It is the policy of (Named Hospital) to provide a safe environment for patients through the identification of patients at risk for falls. The purpose of this policy is to provide guidelines for: Screening, Identification, Preventative Interventions, Protective Interventions, Hand-off communication, Documentation ...D. Morse Fall Scale: A method of assessing a patient's likelihood of falling in the adult population ...using the Morse Fall Scale (MFS) ...MFS scores of 25-44 are considered to be at medium risk for falling (Level II) ...Preventative Interventions for Adult Patients at Medium Risk (MFS Level II) for Falls ...Offer assistance with hygiene and mobility ...Refer to Physical therapy, as appropriate ...Discuss fall risk level and associated interventions in hand off communication upon transfer of care to next shift/unit ...Place Yellow armband on patient ..."

Observation on 02/28/2023 at 1230 during tour revealed Patient #4 was a vision impaired patient deemed as a Moderate Fall Risk through Nursing Morse fall scoring of 35. During tour Patient #4 ambulated in the room unassisted without a yellow armband to identify the patient as a fall risk patient and without use of a chair or personal alarm. Observation revealed Patient #4 did not use the call bell to request assistance.

1. Closed medical record review on 02/28/2023 revealed Patient #2 was a 35-year-old female admitted to the hospital on 12/29/2022 for Acute Kidney Injury and Diarrhea. Record review on 02/28/2023 of the History and Physical completed on 12/29/2022 at 1253 by the admitting Medical Doctor (MD) revealed Patient #2 was positive for Cryptosporidium (a microscopic parasite that causes a typical 7-day course of diarrhea). Review revealed Patient #2 had a history of right eye impaired vision and left eye blindness present on admission. Record review of the Nursing Assessment on 12/29/2022 at 0200 completed by the admitting Registered Nurse (RN) revealed Patient #2 was scored on the Morse Fall Risk scoring as a 35 which was assessed as a Medium/Moderate Fall Risk. Review of the Plan of Care revealed on 12/29/2022 a guidance of care included "...Intervention: Provide assistance with activity ...Teach fall prevention measures ...Implement Fall Prevention Program based on Fall & Injury Assessments for Medium Fall Risk (Level II) patient with a Morse Fall Score of 25-44 ...Assist activities of daily living ..." Record review of the Nursing Flowsheets revealed on 12/29/2022 at 0200 the nursing staff initiated the use of a Bed and Personal alarm for Patient #2. Record review of the Nursing Flowsheets on 01/03/2023 at 0737 through 01/04/2023 at 0705 revealed no evidence of the use of a Bed and Personal alarm for Patient #2. Review of Nursing/Ancillary Notes on 01/04/2023 at 0620 the assigned RN #1 documented, "Found pt (patient) sitting on her bottom on the floor in bathroom. Pt stated she used her walker to get into the bathroom but put the walker outside the bathroom door and walked into the bathroom, at which time, Pt said that her left knee gave out on her ...Provider paged to make aware of fall. Record review revealed Patient #2 was provided care by the RN for the injury sustained during the fall and thereafter Patient #2 was insistent on leaving the hospital. Discharge Condition: Disposition: Patient discharged to Left Against Medical Advice in stable condition. No discharge procedures on file ..." Record review of the AMA Discharge Summary on 01/04/2023 at 1203 revealed the MD provided patient with a list of medication changes and notification of future appointments. Record review revealed on 01/04/2023 at 1646 patient was released from the hospital AMA to home.

Interview on 03/01/2023 at 1455 with the assigned RN for Patient #2 on 01/03/2023 night shift 1900 through 01/04/2023 at 0700 revealed the RN worked at the hospital for 5 years. The RN could not recall any communication during hand off shift report from the previous RN to identify Patient #2 as being non-compliant with the use of the call bell. The RN could not recall any communication with the assigned CNA (Certified Nursing Assistant) for Patient #2 to inform of the need to remain with the patient during ambulation assistance to the bathroom. Interview revealed Patient #2 had an unwitnessed fall on 01/04/2023 at 0606. The RN could not recall the use of the bed/personal alarm for Patient #2. The RN assisted with the cleaning and applied a dry dressing to the foot of Patient #2 after the fall. The RN notified Nursing Leadership, notified the medical provider and participated in the Post-Fall Huddle to review the events of the fall and implementation of all necessary precautions to be applicable for Patient #2. Interview revealed it was the expectation of staff to communicate the need to stay with fall risk patients when patient assistance was needed and to apply needed interventions for safety.

Interview requested with RN assigned to Patient #2 on dayshift 12/29/2022, 01/01/2023, 01/02/2023 and 01/03/2023 was unavailable for interview.

2. Medical record review revealed Patient #4 presented on 02/26/2023, was a 61-year-old female with a chief complaint of painless total left eye vision loss. Review revealed on 02/27/2023 through time of discharge had a Morse Fall Risk score of 35, Medium Fall Risk (Level II). Review revealed Patient #4 had an identified Plan of Care problem list which included "...Safety ...Perform Falls/Injury Risk Assessments ...Implement Fall Prevention Program based on Fall & Injury Assessments for Medium Fall Risk (Level II) patients with a Morse Fall Score of 25-44 ..." Review revealed the Nursing Flowsheet on 2/27/2023 included the use of personal/individual alarm usage and "No" Fall Risk Armband. Review revealed on 2/28/20230921 through 02/28/2023 1900 failed to reveal the use of alarm device. Record review revealed Patient #4 remained an active inpatient during the survey.

Interview with Patient #4 on 02/28/2023 at 1300 revealed the patient presented to the hospital for left acute monocular vision loss with a history of right eye impaired vision. Patient #4 did not have use of a yellow fall risk armband. Patient #4 was alert and oriented to person place situation and was aware that the use of call bell for all assistance was necessary for patient safety. Interview revealed Patient #4 had failed to use the call bell on observation and did not have use of a bed/personal alarm for safety for the identified Morse Fall Scale of 35 upon admission.

Interview with the assigned dayshift RN for Patient #4 on 02/28/2023 at 1322, revealed the RN had worked at the hospital almost 30 years. The RN did not recall if there was communication during hand off from the previous shift in regards to Patient #4 in need of a yellow armband to identify patient as a fall risk. The RN could not recall if there was communication with the current assigned Certified Nursing Assistant (CNA) for Patient #4 to inform the staff member of the fall risk. The RN would reinforce with Patient #4 the educational fall risks, and the need to use the call bell for any needs. The RN would communicate with the CNA the need to remain with the patient for any assistance provided. Interview revealed Patient #4 should have a yellow armband on and the RN would provide the armband at the completion of the interview, apply the use of the personal/individual alarm and inform the CNA of the fall risk for Patient #4.




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B. Review on 02/28/2023 of the hospital policy titled Standards of Nursing Care-Adult Patient, last revised 09/02/2021 revealed "...Purpose: The purpose of this policy is to outline general standards of nursing care for the adult patient...4. Patient Hygiene and Comfort: ...d. Nursing staff will assist patient to maintain integrity of skin by assessment of patient's skin at least every shift and assisting bed-restricted patients to turn at least every 2 hours...Turns and patient position will be documented.... e. Nursing staff will provide skin care to all bony prominences and/or reddened areas..."

Review on 03/01/2023 of the Grievance received 01/20/2023 entered by Patient Care Representative #11 revealed "...A patient's daughter expressed concern regarding her mother's bedsores on her bottom and on her heels. She says she is not going to agree to her mother being discharged before we get these sores healed up...The concern has been reported to the attending physician for review and follow-up..." Review of the Grievance revealed Patient #1 had developed two pressure injuries during her hospitalization from 01/10/2023 through 01/20/2023.

Closed medical record review on 02/28/2023 revealed Patient #1, an 89-year-old female admitted on 01/10/2023 at 2249 for right hip and right-hand fracture. Initial Skin Assessment dated 01/10/2023 at 2319 by Registered Nurse (RN) #1, and RN #2 revealed no pressure injuries present on admission. Physician Orders dated 01/11/2023 by Medical Doctor (MD) #3 revealed "...Turn Patient...every 2 hours...Priority: routine...Comments: Side lying to 30-degree tilt. Avoid lying on affected area (right hip) ..." Review revealed Patient #1 had a right hip surgery repair on 01/12/2023 without complications during surgery. Record review of turning and repositioning for Patient #1 from 01/13/2023 through 01/19/2023 revealed gaps in turning the following times: 01/13/2023-no turning was documented (24 hours), 01/14/2023 from 0000 to 1000 (10 hours), from 1000 to 1930 (9 hours and 30 minutes), 01/15/2023 0700 to 1300 (6 hours), 1301 to 2000 (7 hours), 01/16/2023 from 0600 to 2052 (12 hours and 52 minutes), 01/17/2023 0100 to 0930 (8 hours and 30 minutes), 0931 to 2000 (10 hours and 30 minutes), 2000 to 1/18/2023 2000 (24 hours) 0/12 turns completed. Medical record review revealed Patient #1 was turned 22 of 72 ordered times during 6 days prior to documented skin breakdown of the sacrum (below the lumbar spine and above the tailbone). Review of the In-Patient Wound Service (IPWS) Consultation Report, by Nurse Practitioner (NP) #4 dated 01/19/2023 at 0938 revealed "...Reason for Consultation: Sacral Ulceration...IPWS consulted for wound care recommendations for a sacral pressure injury...Wound area measures 8.0 x 9.0 x 0.1 cm (centimeters). Review of the Nursing/Ancillary Notes dated 01/19/2023 at 1330 by RN #9 revealed "...Pt's daughter at bedside and took patient's socks off to find heels 'looking black'. NP made aware and came to floor to see pt. Upon inspection with NP, deep tissue injury to (B) [both] heels..." Progress Note by NP #5 dated 01/19/2023 at 1330 revealed "... (named patient) with bilateral deep tissue injury to her heels..." Medical record review revealed Patient #1 developed two hospital acquired pressure injuries post-operatively, sacral, and bilateral heels identified in the record on 01/19/2023. Patient #1 was discharged on 01/20/2023 at 1254 to a skilled nursing facility for rehabilitation.

Request to interview RN #7, who did not document turning and repositioning for Patient #1 on 01/13/2023 revealed she was unavailable for interview.

Request to interview RN #9, who identified bilateral heel pressure injuries and cared for Patient #1 on 01/19/2023 revealed she was unavailable for interview.

Telephone interview on 03/01/2023 at 1226 with Wound Care NP #4 revealed she remembered Patient #1. Interview revealed "...it was possible the pressure injury was a result of not turning. I remember the patient did not want to turn for me to examine her sacral wound...I was not aware of her heels if I did not document it..." Interview revealed the wound consult for Patient #1 was only for her sacral wound. Interview revealed the sacral wound could be a result of not being turned every 2 hours.

Telephone interview on 03/01/2023 at 1235 with RN #6 who cared for Patient #1 on 01/18/2023 revealed he remembered the patient. Interview revealed "...I did move her early in the day. Her daughter did page me, I was unavailable when the page came through. I reported the concerns that the daughter was upset that I had not been in the room to my charge nurse, and she spoke with the daughter...I was away from care around 3-5 hours that day in a patient emergency. I don't know if she was turned while I was away..." Interview revealed RN #6 was assisting another patient and was unavailable to turn Patient #1 during part of day shift 01/18/2023. Interview revealed Patient #1 was not turned every 2 hours per hospital policy and physician orders.

Interview on 03/01/2023 at 1450 with Charge Nurse (CN) #8 revealed she remembered Patient #1. Interview revealed "...I was the CN and had a patient assignment...I remember speaking with the daughter who was very concerned a nurse had not been in for care for an extended time...It's possible the patient was not turned..." Interview revealed it was possible Patient #1 was not turned during her nurse's absence while caring for another patient. Interview revealed Patient #1 was not turned every 2 hours per hospital policy and physician orders.

Interview on 03/01/2023 at 1605 with Nurse Manager (NM) #10 revealed pressure injury prevention was an expectation for the orthopedic unit. Interview revealed the expectation was to turn and reposition dependent patients every 2 hours. Interview revealed hospital policy was not followed for Patient #1.

Interview on 03/02/2023 at 1004 with the attending Orthopedic Surgeon, MD #12 revealed Patient #1 was 100% bedbound. Interview revealed "...we have protocols that nurses follow. This patient was 100% functionally impaired with a prolonged hospital stay and many medical issues..." Interview revealed physician orders were in place to turn and reposition Patient #1 every two hours. Interview revealed physician orders were not followed.

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