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Based on staff interview, record review, observations, review of facility policies and procedures, and administrative fall reviews (including Performance Improvement data and internal investigations), the facility failed to protect the Patients Right to receive care in a safe setting by failing to maintain a safe environment for patients at risk of falls. The facility failed to ensure nursing staff were educated on activating bed exit alarms for the 5 types of beds that the facility uses and failed to ensure adequate nursing supervision of patient care for 6 of 13 sampled patients (Patients 5, 8, 4, 11, 10 and 2) identified as high risk for falls by failing to consistently implement the facility high fall risk prevention plan (with interventions including bed and chair alarms, sitters, a yellow armband and yellow non-skid socks to ensure a safe environment). This failure resulted in 1 patient (Patient 5) falling from bed, sustaining a dislocated hip and bleeding in the brain on 11/5/17 (the patient died from the injuries on 11/15/17), and had the potential for other patients identified as high risk for falls to fall and sustain an injury/death. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Patient Rights was not met, and that Immediate Jeopardy (IJ) conditions existed at this facility since 11/5/17, posing a threat of potential serious injury, harm, impairment or death of patients admitted with high fall risk factors. The total sample size was 13. The facility census was 109.

The failure to implement immediate effective action plans had the potential to affect the care of all patients in the facility. The administrative staff implemented measures to remove the immediate jeopardy noncompliance on 1/24/18 by implementing the following:

-Effective immediately (1/19/18) the Registered Nurse (RN) will verify during hourly rounding that all acute medical/surgical inpatients have the universal safety precautions in place. The RN verifies the Morse Fall Risk Scale is completed and for those patients whose scores are higher than 45 (high risk) or have a positive ABCS (age, bones, coagulation, surgery) assessment, the nurse will implement a yellow armband, yellow non-skid socks, yellow high risk signage and a gait belt in room to use when up. If the patient scores higher than 45 on the Morse Fall Risk Scale or has a positive ABCS assessment AND the patient is confused, impulsive, does not recognize their own limitations or is unable to teach back the use of the call light AND has failed the use of other interventions, the RN will verify the above interventions were implemented AND the use of a bed or chair alarm, side rails not utilized for fall prevention, the bed maintained in low position whenever the patient is not receiving direct care and/or Hi/Lo bed with floor mats in place.
-Education for the use of an algorithm to guide the use of a safety advocate (sitter) will be developed and implemented by 1200 on 1/24/18. The need for a safety advocate (sitter) will be assessed upon identification of high risk for fall or high risk for injury by the bedside nurse. If the algorithm indicates that a safety advocate (sitter) is needed, the bedside nurse will notify the house supervisor and the patient will be placed in a 1:1 with a safety advocate (sitter). The continued need for a safety advocate (sitter) will be reassessed and documented every 2 hours by the bedside nurse.
-The facility has a rental agreement with (a company) for high-low beds. Effective immediately, 5 high low beds will be available in house and (the company) will supply additional high low beds if needed. Effective immediately at staffing huddle 7 days a week, house supervisor and supply staff will validate "how many beds are in house, how many beds are in use" to identify if there is a need to proactively procure additional beds.
-Effective by 1200 on 1/24/18, during bedside report, a two-person visual verification of the status of the bed alarms will take place by oncoming/off going staff. All RN's will sign an attestation acknowledging this expectation immediately on 1/24/18 if on duty or prior to working their shift if not currently on duty. Nursing leadership will audit every shift that the two-person visual verification is occurring, this will be done daily through direct observation of bedside shift handoff for 100% of patients on a bed alarm per the team coordinator report with a goal of 100% compliance.
-Beginning 1800, 1/19/18, Operations Directors and Managers, House Supervisors, and Clinical Nurse Specialists began re-educating all clinical staff (which included a return demonstration) on how to work the bed alarms and alarm sensitivity training prior to them working their next shift. Training was made available daily from 0600 to 0730 and 1800 to 1930 from 1/19/18 through 1/24/18 with additional training opportunities made available by the Clinical Nurse Specialist, Nursing Directors and House Supervisors outside of these hours. The training will be tracked via LEARN (computer) program, a return demonstration was required before beginning their next work shift. All staff on leave of absence who fall into the identified staff categories (CNO [Chief Nursing Officer], all clinical Directors, Managers, Supervisors and leaders who round in patient rooms, all RN's, CNS [Clinical Nurse Specialist], LPN's [Licensed Practical Nurses], CNA's [Certified Nurse Assistant], techs, all ancillary employees who provide services in patient rooms [PT-physical therapy, OT-occupational therapy, Speech, Pharmacy, Dieticians, Phlebotomists, Lab Med Techs, Radiology/Mammography techs, all dialysis employees and quality nurses), with a work location at this facility will be trained before working.
-Beginning 1800, 1/19/18, clinical staff were trained on the key elements of the Fall Prevention Program by completing Fall Prevention Competency & Validation on-line training module. Successful completion of the training was required before beginning their next work shift or by January 31, 2018, whichever occurs first. The training includes: the definition of high risk for fall or risk of injury, interventions to reduce risk for fall or risk for injury, frequency of assessment for patient safety, documentation of assessments and interventions. The training will be tracked via LEARN program. All staff on leave of absence who fall into the identified staff category will be assigned a LEARN mandatory training which will be required to be completed prior to returning to patient care, verified by nursing leadership. Nursing leadership will conduct a daily audit on all patients to verify the following, with a goal of 100% compliance: Assessment completed by the RN assigned to the patient and documented in the electronic health record on admission and at least daily or following any fall occurrence, when a patient condition changes, with any change in level of care, and when returning to the nursing unit following a procedure that altered the patient's level of consciousness; If the patient is identified as high risk for fall or injury, RN implemented and documented at least daily or following any fall occurrence, when a patient condition changes, with any change in level of care, and when returning to the nursing unit following a procedure that altered the patient's level of consciousness in the electronic health record the following precautions: Yellow sign, yellow wristband, yellow no-skid socks, and additional safeguards as determined by the findings of the assessment; The RN documented the assessment and interventions in the plan of care (assessment parameters) in the electronic health record per policy.
-Starting at 1200 on 1/24/18, all RN's will complete an attestation acknowledging that they have read and understand the Fall Prevention Program and Risk for injury policy. This will be completed at the start of each shift until 100% of RN's have completed the attestation.

Refer to A 144.

Based on staff interview, record review, observations, review of facility policies and procedures, and administrative fall reviews (including Performance Improvement data and internal investigations), the facility failed to protect the Patients Right to receive care in a safe setting by failing to maintain a safe environment for patients at risk of falls. The facility failed to ensure nursing staff were educated on activating bed exit alarms for the 5 types of beds that the facility uses. The facility failed to ensure adequate nursing supervision of patient care for 6 of 13 sampled patients (Patients 5, 8, 4, 11, 10 and 2) who were identified as high risk for falls by failing to consistently implement the facility high fall risk prevention plan (with interventions including bed and chair alarms, sitters, a yellow armband and yellow non-skid socks to ensure a safe environment). This failure resulted in 1 patient (Patient 5) falling from bed, sustaining a dislocated hip and bleeding in the brain on 11/5/17 (death from subsequent injuries occurred on 11/15/17), and had the potential for other patients identified as high risk for falls to fall and sustain death/injury. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Patient Rights was not met, and that Immediate Jeopardy (IJ) conditions existed at the facility since 11/5/17 posing a threat of potential serious injury, harm, impairment or death of patients at the facility identified as having the potential as a high fall risk. The total sample size was 13. The facility census was 109.

Findings are:

A. Observations on tour/rounds for 40 patients identified by the facility as having a high fall risk on 1/16/18 from 4:50 PM to 5:48 PM with nursing leadership and quality/risk staff revealed 16 of the 40 failed to have bed or chair alarms on (39%). The 16 patients were located on multiple inpatient units with the exception of the Progressive Care Unit. The patient sample included 4 of the 16 patients (who were identified as high fall risk) who failed to have bed/chair alarms activated when observed on 1/16/18 (Patients 2, 4, 8 and 10). Review of the Root Cause Analysis conducted after the patient 5's fall on 11/5/17 and subsequent death ( from injuries related to the fall on 11/15/17), found the facility implemented corrective actions for the Progressive Care unit but did not implement any corrective actions for the remainder of the hospital. Patient 5's bed alarm was not turned on at the time of the fall. A review of Patient 11's medical record revealed that on 1/21/18 at 4:15 PM the patient was found in a kneeling position on the floor. Patient 11's alarm was not turned on at the time of the fall, despite a fall risk score of 110.

B. Interviews during the observation/tour rounds on 1/16/18 found that nurses were not familiar with the beds or how to turn on alarms. Registered Nurse (RN) L stated her patient with high fall risk score ( non sampled patient), was to have an alarm on and confirmed it was not on. RN L stated "I am a float pool nurse and supposed to get this information in report."RN M verified the bed alarm was not on for an assigned high fall risk patient (non sampled patient) stating "I usually work on another floor and am not familiar with these beds." RN M then attempted to activate the bed alarm and was unable to do so stating "these alarm systems are different than on the beds I usually work with." Interview with RN Director of Progressive Care unit on 1/18/18 at 10:30 AM revealed the RN Director was unaware of how to turn on the bed alarms on the types of beds used on Progressive Care.

C.


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E. A review of an Incident Report dated 11/5/17 at 10:45 PM revealed that Patient 5 climbed out of bed and fell hitting their head. Patient 5 sustained an acute intracranial hemorrhage (bleeding in the brain) and dislocated a newly repaired hip. The patient passed away at the hospital 10 days after the fall related to complications due to the fall. At the time of the fall THE BED ALARM WAS NOT ACTIVATED AND NOT SOUNDING, even though the patient was assessed as being a high risk for falls with a Morse Fall Score of 100-110. (45 or above is considered to be a 'high risk' for falls).

F. A review of Patient 11's medical record revealed that on 1/21/18 at 4:15 PM the patient was found in a kneeling position on the floor. Patient 11's ALARM WAS NOT ACTIVATED AND NOT SOUNDING, even though the patient was assessed as being a high risk for falls with a Morse Fall Score of 110.

G. A review of a Nursing Status Report sheet on 1/16/18 at 10:39 AM for Pt 8 and an observation on of Patient 8 on 1/16/18 at 3:10 PM revealed Patient 8 was resting quietly in bed. Patient 8 had a yellow sign on door, had on a yellow bracelet and yellow slippers; three side rails were up and THE BED ALARM WAS NOT ACTIVATED, even though the patient was assessed as being a high risk for falls with a Morse Fall Score of 60.

H. A review of Patient 4's medical record and observations of Patient 4 revealed:
- An observation on 1/16/18 at 3:50 PM showed Patient 4 had a yellow sign on the door, had on a yellow bracelet and yellow slippers; three side rails were up and THE BED ALARM WAS NOT ACTIVATED.
- An observation on 1/16/18 at 5:20 PM showed Patient 4 had a yellow sign on the door, had on a yellow bracelet and yellow slippers; three side rails were up and THE BED ALARM WAS NOT ACTIVATED.
- An observation on 1/17/18 at 5:20 PM showed Patient 4 had a yellow sign on the door, had on a yellow bracelet and yellow slippers; three side rails were up and THE BED ALARM WAS NOT ACTIVATED.
Patient 4's alarms were not activated, even though the patient was assessed as being a high risk for falls with a Morse Fall Score of 100 and a history of dementia (confusion).

I. Record review revealed Patient 10 was admitted on 1/11/18 for skin graft surgery related to skin ulcers on the lower legs. On 1/16/17 at 4:25 PM the record identifies the patient's Morse fall risk score was 85. Risk factors identified included a history of falls, diagnoses, ambulatory aid, Intravenous line (IV), weakness, the use of anticoagulation (medications used to prolong blood clotting), and a recent surgical procedure. The patient was observed during safety rounds (of high fall risk patients) on 1/16/17 from 4:50 PM - 5:48 PM. Patient 10 was in bed with THE BED ALARM NOT ACTIVATED. According to Patient 10's Plan of Care, fall risk interventions to be provided to this patient were a yellow armband, yellow door sign, non skid socks, reorientation to person place and time, gait belt (belt used by staff to help support the patient with transfer/ambulation) and that the patient was located near the nurses station. Intervention for bed alarms/Tab (chair) alarm was blank, indicating they were not being provided. The section stating "Clinical Key handout on Fall Prevention given w [with]/ teach - back" is identified with "N" for No. The patient discharged to a nursing facility on 1/17/18.

J. Record review revealed Patient 2 was transferred to the hospital on 1/14/18. Diagnosis included acute encephalopathy (disease in which the functioning of the brain is affected), history of stroke, seizures, altered mental state, influenza A and cancer. The patient did not speak English. The patient record documents the patient is confused and agitated at times. On 1/14/18 the patient had a sitter to maintain the patients safety. On 1/15/18 the patient was more cooperative and with family present a sitter was not provided. On 1/16/18 the patient required use of a sitter during the night for safety. Review of the Electronic Medication Administration Record (EMAR) noted the patient required the use of prn (as needed) Haldol 1 milligram IV at 8:02 AM on 1/16/18 for severe agitation. Haldol is an antipsychotic medication which can be used to decrease agitation/aggression.
The Morse fall score was done daily since admission and scored as high risk each day. The Plan of Care 1/14/17 included high fall risk and to be on interventions in the Fall Risk Protocol.
Observation on 1/16/18 at 3:55 PM found the patient confused and in bed with a family member present. The family said the patient gets very confused and thinks his sheets are on fire or that he has to go to work and tries to get up frequently. Family reported they try to stay when there is no sitter. The patient is on seizure precautions and has padded side rails. He had yellow socks on. THE BED ALARM WAS NOT ACTIVATED. This was verified with the Quality Manager during the observation. On 1/16/17 at 5 PM the nurse documented the fall risk score was 75. Documentation of interventions to address this patient's high fall risk potential on 1/16/17 included yellow armband, yellow door sign, non skid socks. These were identified with a "Y" for yes beside the intervention. Additional interventions on the assessment included bed alarms/tab on, clinical key handout on fall prevention with teach-back, gait belt, remain with patient at arms length and in sight while toileting, hi-low bed with floor mats, frequent reminders to patient/family to call for help, encourage family to stay with patient, reoriented to person, place and time, patient located near nurses station and assess for functional ability were all left blank indicating these interventions were not being utilized. Additional observation on 1/17/18 at 3:58 PM found the patient in bed with the bed alarm on and family and sitter present in the room. Record review noted the patients fall risk on 1/17/18 remained high at 75.

The facility failed to have an effective Quality Assessment and Performance Improvement Program. This finding was based on record review of the facility Quality Assurance plan and procedure for serious safety events, staff interviews and record review of the facility action plan post fall of patient 5 on 11/5/17. The patient died from injuries related to the fall on 11/15/17. After completing a Root Cause Analysis (RCA) and developing an Action Plan, the facility failed to implement hospital wide changes to protect patients identified as being a 'high risk' from falls and potential subsequent serious injuries/death. This failure has the potential to impact all patients at the facility identified as being at risk for falls. The facility census was 109. The sample size was 13. See also deficiency at A-286, A-144 and A-395.

Findings are:

A. Record review of the undated facility investigation/RCA (Root Cause Analysis) and an interview with the facility Quality Team including the Quality Director, Risk Manager, CNO (Chief Nursing Officer) and other team members on 1/18/18 at 10:30 AM regarding Pt 5's 11/5/17 fall resulting in significant injury/death revealed the Quality Team noted some area's to improve regarding fall interventions and focused on the specific staff member and the unit the incident occurred. The team identified the following issues:
-A knowledge gap about the use of side rails as restraint and as fall intervention.
-No standardized checklist to use during handoff. Bedside report is to include if bed alarms are needed for patients and staff are to validate that the bed alarms are on when needed.
-No objective standardized process to determine if new RN's are prepared to come off orientation.
An interview with the Risk Manager during the Quality Team meeting revealed, "The event happened on 11/5/17. We met as a group to discuss it. We talked to the RN (RN P) involved, and (RN P said, "I assumed the alarm was on. RN P had pushed the buttons to activate the bed alarm.") RN P indicated that (gender) pushed the buttons (gender) thought turned it on, but was not aware of the correct steps to activate the bed alarm. We then went on to do the RCA and found that there needed to be a more standardized hand off of patients with alarms checked on the shift to shift report. We developed and ordered a check list to go over during hand off called a "Badge Buddy". We addressed it with the unit (Progressive Care) that this occurred on and talked about it with that staff, and initiated some audits on the unit. We'll do 30 audits per month for 4 months on high risk patients on that unit and verify the bed alarms are on-the fall risk protocol is followed. We talked to a company to possibly get more hi low beds, no arrangement has been made yet. The Action Plan was not taken across the board for falls, we just focused on (the unit) it occurred for the implementation of the action plan."

B. Review of the facility policy titled "Sentinel Event and Significant Events: Staff Response" last approved 02/2016. The policy defines a Sentinel Event as "An unexpected occurrence involving death or serious physical or psychological injury (as with a rape event), or the risk thereof which (as determined by the risk analysis) includes any process variation that if recurred would carry a significant chance of a serious adverse outcome. The facility has "Safety First" documents to guide staff to conduct the investigation and RCA. The document titled "Root Cause Analysis (RCA) Charter and Participation Request" stated "The investigation and root cause analysis must be completed within 45 days." The Safety First documents do not guide staff to ensure learning takes place throughout the hospital to protect other similar patients from risk of harm.
The facility investigation/RCA identified issues related to the Pt 5's fall with significant injury. The facility followed up with the staff on the Progressive Care unit only where the incident occurred but failed to do a systemic analysis of the fall program and implementation. The facility failed to provide re-education to all nursing staff to prevent future falls with the potential for serious injury for those patients identified as high risk throughout the hospital. Hospital wide quality data for falls provided by the hospital from 9/1/17 through 1/17/18 revealed patient falls peaked with 14 in November, 12 in December and 8 in the first 17 days of January.

Based on record review of the facility Quality Assurance plan and procedure for serious safety events, staff interviews and record review of facility action plan post fall of patient 5 on 11/5/17, and subsequent death from injuries related to the fall on 11/15/17, the facility failed to implement changes hospital wide to protect patients from falls and potential subsequent injuries/death. This failure has the potential to impact all patients identified as being at risk for falls. The total sample size was 13. The facility entrance was 109. See also deficiencies at 0144 and 0395.

Findings are:

A. Record review of the undated facility investigation/RCA (Root Cause Analysis) and an interview with the facility Quality Team including the Quality Director, Risk Manager, CNO (Chief Nursing Officer) and other team members on 1/18/18 at 10:30 AM regarding Pt 5's 11/5/17 fall resulting in significant injury/death revealed the Quality Team found area's to improve regarding fall interventions, however, they only focused on the specific staff member and the unit where the incident occurred. The team identified the following issues:
-A knowledge gap about the use of side rails as restraint and as fall intervention.
-No standardized checklist to use during handoff. Bedside report is to include if bed alarms are needed for patients and staff are to validate that the bed alarms are on when needed.
-No objective standardized process to determine if new RN's are prepared to come off orientation.
An interview with the Risk Manager during the Quality Team meeting revealed, "The event happened on 11/5/17. We met as a group to discuss it. We talked to the RN involved, and (the RN said, "assumed the alarm was on") We then went on to do the RCA and found that there needed to be a more standardized hand off of patients with alarms on the shift to shift report. We developed and ordered a check list to go over during hand off called "Badge Buddy". We addressed it with the unit (Progressive Care) that his occurred on and talked about it with that staff, and initiated some audits on the unit. Will do 30 audits per month for 4 months on high risk patients on that unit and verify the bed alarms are on-the fall risk protocol is followed. We talked to a company to possibly get more hi low beds, no arrangement has been made yet. The Action Plan was not taken across the board for falls, we just focused on (the unit) it occurred for the implementation of the action plan."
The Quality Director revealed, "We are aware we have issues about falls. We recognized that with our fall policy, we have 2 standards of care going on at the same time. That does not conform with our fall policy." "This fall (11/5/17) brought it to light we have urgency with issues related to fall prevention, but not all falls are all of a sudden (related to system wide quality review), this was 1 large error. Not everything gets on the rush list." "Yes we did identify this as a sentinel event (An unanticipated event in a healthcare setting resulting in death or serious physical injury to a patient.)"

B. Record review of the facility policy titled "Quality, Safety, and Performance Improvement Plan FY [Fiscal Year] 2018 approved 07/2017 identifies under the section titled "Model/Methods of Improvement" that "CHI Health expects leaders to identify processes to improve based on data, unexpected events,or performance levels with opportunities for improvement." The policy also states that "Lessons learned from root cause analysis, system, and/or process failures are disseminated to team members who provide related services."
Review of the facility policy titled "Sentinel Event and Significant Events: Staff Response" last approved 02/2016. The policy defines a Sentinel Event as "An unexpected occurrence involving death or serious physical or psychological injury (as with a rape event), or the risk thereof which (as determined by the risk analysis) includes any process variation that if recurred would carry a significant chance of a serious adverse outcome. The facility has "Safety First" documents to guide staff to conduct the investigation and RCA. The document titled "Root Cause Analysis (RCA) Charter and Participation Request stated "The investigation and root cause analysis must be completed within 45 days." The Safety First documents do not guide staff to ensure learning takes place throughout the hospital to protect similar at risk patients from risk of harm.
The facility investigation/RCA identified issues related to the Pt 5's fall with significant injury. The facility followed up with the staff and Progressive Care unit only but failed to do a systemic analysis of the facility fall program and implementation. The facility failed to provide re-education to all nursing staff to prevent future falls with the potential for serious injury for those patients identified as high risk throughout the hospital. Hospital wide quality data for falls provided by the hospital from 9/1/17 through 1/17/18 revealed patient falls peaked with 14 in November, 12 in December and 8 in the first 17 days of January.

Based on staff interview, record review, observations, review of facility policies and procedures, and administrative fall reviews (including Performance Improvement data and internal investigations), the facility failed to maintain a safe environment by ensuring nursing staff were educated on how to activate bed alarms for the 5 types of beds that the facility uses. The facility failed to ensure the nursing staff provided adequate supervision of care related to failure to ensure fall precautions/interventions for 6 of 13 sampled patients (Patients 5, 8, 4, 11, 10 and 2) who had been identified as being at a high risk for falls. The nursing staff failed to consistently implement the high fall risk prevention plan with interventions including bed and chair alarms, sitters, a yellow armband and yellow non-skid socks to ensure a safe environment. Nursing staff failed to update the Care Plan for 4 of the 13 sampled patients (Patients 5, 8, 4, and 1) as their condition changed. These failures resulted in 1 patient (Patient 5) falling from bed, sustaining a dislocated hip and bleeding in the brain on 11/5/17 (the patient died 11/15/17 from the injuries sustained in the fall); and had the potential for other patients in the facility who were identified as being at a high risk for falls to fall and sustain an injury/death. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Nursing Services was not met, and that Immediate Jeopardy (IJ) conditions existed since 11/5/17 posing a threat of potential serious injury, harm, impairment or death of patients in the facility who were identified as being at a high risks for falls. The failure to implement immediate effective action plans has the potential to affect the care of all patients in the facility. Sample size was 13, patient census at the time of the survey was 109.

The administrative staff implemented measures to remove the immediate jeopardy noncompliance on 1/24/18 by implementing the following:

-Effective immediately (1/19/18) the Registered Nurse (RN) will verify the during hourly rounding that all acute medical/surgical inpatients have the universal safety precautions in place. The RN verifies the Morse Fall Risk Scale is completed and for those patient's whose scores are higher than 45 (high risk) or have a positive ABCS (age, bones, coagulation, surgery) assessment the nurse will implement a yellow armband, yellow non-skid socks, yellow high risk signage and a gait belt in room to use when up. If the patient scores higher than 45 on the Morse Fall Risk Scale or has a positive ABCS assessment AND the patient is confused, impulsive, does not recognize their own limitations or is unable to teach back the use of the call light, the RN will verify the above interventions were implemented AND the use of a bed or chair alarm, side rails not utilized for fall prevention, the bed maintained in low position whenever the patient is not receiving direct care and/or Hi/Lo bed with floor mats in place if the patient is confused, impulsive, does not recognize their own limitations or is unable to teach back the use of the call light AND the patient has failed the use of other interventions.
-Education for the use of an algorithm to guide the use of a safety advocate (sitter) will be developed and implemented by 1200 on 1/24/18. The need for a safety advocate (sitter) will be assessed upon identification of high risk for fall or high risk for injury by the bedside nurse. If the algorithm indicates that a safety advocate (sitter) is needed, the bedside nurse will notify the house supervisor and the patient will be placed in a 1:1 with a safety advocate (sitter). Continued need for a safety advocate (sitter) will be reassessed and documented every 2 hours by the bedside nurse.
-The facility has a rental agreement with (a company) for high-low beds. Effective immediately, 5 high low beds will be available in house and the company will supply additional high low beds as needed. Effective immediately at staffing huddle 7 days a week, house supervisor and supply chain will validate how many beds in house, how many beds in use to identify need to proactively procure additional beds.
-Effective by 1200 on 1/24/18, during bedside report, a two-person visual verification of the status of the bed alarm will take place by oncoming/offgoing staff. All RN's will sign an attestation acknowledging this expectation immediately on 1/24/18 if on duty or prior to working their shift if not currently on duty. Nursing leadership will audit every shift that the two-person visual verification is occurring, this will be done daily through direct observation of bedside shift handoff for 100% of patients on a bed alarm per the team coordinator report with a goal of 100% compliance.
-Beginning 1800, 1/19/18, Operations Directors and Managers, House Supervisors, and Clinical Nurse Specialists began re-educating all clinical staff (including a return demonstration) on how to work the bed alarms and alarm sensitivity training prior to them working their next shift. Training was made available daily from 0600 to 0730 and 1800 to 1930 from 1/19/18 through 1/24/18 with additional training opportunities made available by the Clinical Nurse Specialist, Nursing Directors and House Supervisors outside of these hours. The training will be tracked via a LEARN (computer) program, a return demonstration was required before beginning their next work shift. All staff on leave of absence who fall into the identified staff categories (CNO [Chief Nursing Officer], all clinical Directors, Managers, Supervisors and leaders who round in patient rooms, all RNs, CNS [Clinical Nurse Specialist], LPN's [Licensed Practical Nurses], CNAs [Certified Nurse Assistant], techs, all ancillary employees who provide services in patient rooms [PT-physical therapy, OT-occupational therapy, Speech, Pharmacy, Dieticians, Phlebotomists, Lab Med Techs, Radiology/Mammography techs, all dialysis employees and quality nurses), with a work location at this facility will be trained before working.
-Beginning 1800, 1/19/18, clinical staff were trained on the key elements of the Fall Prevention Program by completing Fall Prevention Competency & Validation on-line training module. Successful completion of the training was required before beginning their next work shift or by January 31, 2018, whichever occurs first. The training includes: the definition of high risk for fall or risk of injury, interventions to reduce risk for fall or risk for injury, frequency of assessment for patient safety, documentation of assessments and interventions. The training will be tracked via the LEARN program. All staff on leave of absence who fall into the identified staff category will be assigned a LEARN mandatory training which will be required to be completed prior to returning to patient care, verified by nursing leadership. Nursing leadership will conduct daily audit on all patients to verify the following, with a goal of 100% compliance: Assessment completed by the RN assigned to the patient and documented in the electronic health record on admission and at least daily or following any fall occurrence, when a patient condition changes, with any change in level of care, and when returning to the nursing unit following a procedure that altered the patient's level of consciousness. If the patient is identified as high risk for fall or injury, RN implemented and documented at least daily or following any fall occurrence, when a patient condition changes, with any change in level of care, and when returning to the nursing unit following a procedure that altered the patient's level of consciousness in the electronic health record the following precautions: yellow sign, yellow wristband, yellow no-skid socks, and additional safeguards as determined by the findings of the assessment. The RN documented the assessment and interventions in the plan of care (assessment parameters) in the electronic health record per policy.
-Starting at 1200 on 1/24/18, all RNs will complete an attestation acknowledging that have read and understand the Fall Prevention Program and Risk for injury policy. This will be completed at the start of each shift until 100% of RNs have completed the attestation.

Refer to A-395 and A-396

Based on staff interview, record review, observations, review of facility policies and procedures, and administrative fall reviews (including Performance Improvement data and internal investigations), the facility failed to maintain a safe environment by ensuring nursing staff were educated on the activation mechanisms of alarms for the 5 types of beds that the facility uses and failed to provide adequate nursing supervision for 6 of 13 sampled patients (Patients 5, 8, 4, 11, 10 and 2) identified as being at a high risk for falls. The nursing staff failed to consistently implement the high fall risk prevention plan with interventions including bed and chair alarms, sitters, a yellow armband and yellow non-skid socks to ensure a safe environment for the patients. Nursing staff also failed to update the Nursing Care Plan for the patients as their condition changed for 4 of 13 sampled patients (Patients 5, 8, 4, and 1). These failures resulted in 1 unsupervised fall, patient (Pt 5) who fell from bed, sustaining a dislocated hip and bleeding in the brain on 11/5/17 (the patient died on 11/15/17 from the subsequent injuries); and had the potential for injury or death for other patients identified as high risk for falls. These failures resulted in the determination by the Centers for Medicare and Medicaid (CMS) that the Condition of Participation for Nursing Services was not met, and that Immediate Jeopardy (IJ) conditions existed since 11/5/17 posing a threat of potential serious injury, harm, impairment or death of patients admitted with high fall risks identified. The total sample was 13. The facility census was 109.

A removal of the IJ condition occurred on 1/24/18 following the implementation of measures to remove the immediate jeopardy noncompliance. See A 395 and A 396.

Findings are:

A. A review of Patient 5's medical record revealed that Patient 5 arrived to the hospital on 10/29/17 for emergency services following 6 recent falls at home and after evaluation was admitted on 10/30/17. The History and Physical (H&P) for Patient 5 dated 10/29/17 revealed the patient was initially admitted for observation pending the results of an MRI (Magnetic Resonance Imaging-an specialized scan). The MRI did identify that Patient 5 had a fractured left hip. The H&P identified that Patient 5 is alert and oriented x (by) 3 (person, place or time)." and psychiatric evaluation was that the patient had grossly normal insight and judgement. A CT (Cat Scan- a specialized scan) of the head on admission showed "No acute intracranial abnormality (no bleeding in brain or other abnormality)."

The Death Summary dated 11/16/17 revealed that Patient 5's Discharge diagnoses included: 1) Death secondary to left hip fracture and subsequent complications; 2) Left hip fracture; 3)Multiple falls; 4) ACUTE INTRACRANIAL HEMORRHAGE SECONDARY TO FALL AND HEAD TRAUMA (bleeding in the brain following a fall at the hospital); and 5) Severe acute toxic encephalopathy (sudden onset of confusion and/or delirium). Patient 5 had a left total hip replacement, following the surgery, Patient 5 developed significant delirium (confusion) and was restless. Patient 5 had thrashed around and subsequently developed a hematoma (a pocket of clotted blood in the tissue) which required going back into surgery for a washout (removal of hematoma) 2 days after the hip surgery. The patient then climbed out of bed 2 days later and fell and hit head sustaining an acute intracranial hemorrhage (bleeding in the brain) and dislocated the newly repaired hip. Patient 5 was moved to the ICU (Intensive Care Unit) and Patient 5's overall condition continued to decline. Ten days after the fall (during which Pt 5 sustained the acute intracranial hemorrhage), the patient was admitted to hospice care (end of life care) and passed away that day.

Review of the "Fall Prevention Program and Risk for Injury Policy" last reviewed 6/2017 revealed:
-Patients will be assessed for fall risk on admission-Adult Acute Care utilized "Morse Fall Risk Assessment Tool."
-A fall risk reassessment is completed; following any fall occurrence; when a patient's condition changes; daily; change in level of care; and when returning to nursing unit following a procedure that altered the patient's level of consciousness.
-Once risk for injury and fall risk assessment are completed; initiate the fall interventions and any additional measures that are individualized to the patient and document interventions in the EMR (electronic medical record); If patient scores as a high risk for falls or risk for injury, update the Fall Plan of Care; Provide and discuss with patient and family, as applicable, patient education on Fall Prevention and document in the EMR.
-Per the facility Fall and Risk for Injury Interventions: High Risk for Fall Prevention Plan include: patient education; assess pt/family understanding of high-risk precautions; request teach-back; evaluate pt nutritional needs; consult dietary if warranted; use nutritional supplement if poor nutritional intake or frequent falls at home; colored armband, colored non-skid socks; when assistance is needed, use a gait belt; FOR PATIENTS THAT ARE CONFUSED, IMPULSIVE, OR CANNOT TEACH BACK FALL PREVENTION INSTRUCTIONS, RECOMMEND THE FOLLOWING: BED AND CHAIR ALARMS, SCHEDULED TOILETING, REMAIN WITH PATIENT ARMS LENGTH AND IN SIGHT WHILE TOILETING; FLOOR PAD AS NEEDED; EVALUATE NEED FOR LOW BED; campus specific fall signage outside the door of room; fall indicator signage inside room and visible to patient; consult with PT (Physical Therapy) and OT (Occupational Therapy) if warranted; Evaluate need for assessing orthostatic blood pressure (blood pressure that falls when position changes) and evaluate the need for medication review.

Review of the Nursing assessments related to Patient 5's fall risk potential using the "Morse Fall Risk Assessment Tool" (An assessment tool that the nurses use to predict the likelihood of falls. The tool assigns specific numbers to 6 items identified as risk factors for falls including; history of falling; diagnosis; ambulatory aid used; Intravenous line; transferring/gait; mental status. The score ranges 0-125 with the range of 0-24=low risk; 25-44=medium risk; 45+=high risk.)
Patient 5's Morse Fall Risk Score from 10/20/17-11/9/17 was 100-110, as Patient 5's overall condition declined the score ranged from 95-55 at the time of death.

Review of the "sitter" schedules for 11/1-11/8/17 and an interview with the Risk Manager on 1/17/18 at 1:40 PM revealed, "(Patient 5) had a sitter on 11/1/17 until 11/4/17 at 2:00 PM. The house supervisor talked with the nurse sitting with (Patient 5) and (gender) was not as agitated, not trying to get up so the sitter was discontinued at 2:00 PM on 11/4/17. The fall occurred on 11/5/17 at 10:45 PM."

Review of Patient 5's charted fall interventions include:
-Yellow armband, non-skid socks and fall signage outside door of room for all assessments from 10/30/17-11/15/17
-In addition to the above interventions the medical record charting also indicated Bed/Tabs (chair) alarms on the following days: 10/30/17; 10/31/17 night shift only ; 11/1/17; 11/4/17 night shift; 11/5/17 night shift; 11/6/17-11/14/17.

A Review of Patient 5's Incident Report for the 11/5/17 fall at 2245 (10:45 PM) with the Risk Manager on 1/17/18 at 2:30 PM revealed, Patient 5 was found on the floor on (gender) back with the abductor pillow (A pillow placed between the patients thighs and attached to the legs with straps to prevent the hip from moving out of the joint.) in place. Patient 5 was on the right side of the bed which had 2 side rails in the upper position. (The left side of the bed had the upper rail in the upper position.) THERE WAS NO ALARM SOUNDING. The patient was assessed and assisted back to bed with the assistance of staff. The Risk Manager had an interview with the RN (RN P) that was providing care for Patient 5 at the time of the fall. RN P told the Risk Manager that (gender) thought the bed alarm was on. RN P had pushed the buttons to activate the bed alarm, but due to the bed being from the orthopedics unit it was different than the other beds on progressive care unit (PCU) that (gender) is used to, so (gender) was not aware of the correct steps to activate the bed alarm. The provider was notified of the fall and orders were received for a CT of the head.

Review of Patient 5's Progress notes and physician orders revealed:
-Hospitalist Physician Progress note dated 11/2/17 at 7:25 AM, "Extreme violent agitation last PM. Hitting and biting." "ABLA (Acute Blood Loss Anemia [loss of blood following surgery]), Acute Toxic Encephalopathy (altered mental status)-avoid narcotics (pain medications)"
-Orthopedic Physician Progress note dated 11/3/17 at 8:00 AM, "Acute increase in confusion and cardiac event (heart issue) last night- awaiting cardiology work up.
-Hospitalist Physician progress note dated 11/3/17 at 9:45 AM, "Agitation better. Able to wake up and state in pain. Needing wrist restraints." "Back to OR (surgery) today to washout incision and remove hematoma."
-Hospitalist Physician Progress note dated 11/4/17 at 11:12 AM, "Much improved! Alert up in chair, pleasant, cooperative, c/o (complain of) hip pain." "Alert not oriented x 3 (person, place or time)."
-Hospitalist Physician Progress note dated 11/5/17 at 9:16 AM, "Pt [Patient] awake, quite hard of hearing, but NAD [no acute distress], wound drain." "new onset A-Fib (heart arrhythmia)
-Hospitalist Advanced Practice RN note dated 11/5/17 at 11:20 PM (FOLLOWING FALL), "CT head now, no contrast".
-Hospitalist Physician Progress note dated 11/6/17 at 12:24 AM, "Called to bedside by RN regarding patient recent fall and new Left Temporo-occipital intraparenchymal hemorrhage (The location of the brain bleed.). Pt upon entering room is confused and unable to follow commands for CN (Cranial Nerve) exam. Called and discussed with Neurosurgeon (a physician that specializes in treatment and surgery of the brain, spine and spinal cord) whom recommends transfer to ICU with Hydralazine (a medication to help treat elevated blood pressure), and repeat CT of the Head in AM."
-Hospitalist Physician Progress note dated 11/6/17 at 9:15 AM, "Pt seen/examined. Last night events noted. Pt denies headache. Fall was unwitnessed but Pt was found on buttocks (bottom). c/o hip pain this am." Portable Left hip X-ray ordered.
-Orthopedic Physician Progress note dated 11/6/17 at 1:00 PM, "Dislocated left total hip, requiring closed reduction (manipulation of dislocated hip to return into the correct position). Knee immobilizer applied and will need abduction brace applied."
-Hospitalist Physician order dated 11/7/17 at 6:47 PM, Pt agitated and restless, "Start on continuous infusion sedation protocol. Precedex (medication given continuously via IV to keep patient sedated) protocol initiated"
-Hospitalist Physician order dated 11/12/17 at 9:00 AM, "Discontinue Precedex"
-Palliative Care (end of life) Provider Progress note dated 11/15/17 at 9:20 AM, "Had RRT (Rapid Response Team) this morning (9:08 AM) for respiratory failure. Placed on Bipap support (machine to help breath). Diagnoses: physical debility (physical decline); acute hypoxic (low oxygen level in blood) respiratory failure, hyperactive delirium (confusion); palliative care; pain; left hip fracture status post total hip, washout, closed reduction 11/6; Intracranial hemorrhage
-Palliative Care Physician order dated 11/15/17 at 11:22 AM, " End of Life Order set."
-Patient passed away at on 11/15/17 at 6:30 PM

A review of the undated facility investigation/RCA (Root Cause Analysis) and an interview with the facility Quality Team including the Quality Director, Risk Manager, CNO (Chief Nursing Officer) and other team members on 1/18/18 at 10:30 AM regarding Patient 5's 11/5/17 fall resulting in significant injury/death revealed the Quality Team found area's to improve regarding fall interventions and focused on the specific staff member and the unit the incident occurred. The team identified the following issues:
-A knowledge gap about the use of side rails as restraint and as fall intervention.
-There is no standardized checklist to use during handoff. Bedside report is to include if bed alarms are needed for patients and staff are to validate that the bed alarms are on when needed.
-There is not an objective standardized process to determine if new RN's are prepared to come off orientation.
An interview with the Risk Manager during the Quality Team meeting revealed, "The event happened on 11/5/17. We met as a group to discuss it. We talked to the RN (RN P) involved, and (RN P said, "I assumed the alarm was on") RN P indicated that (gender) pushed the buttons (gender) thought turned on it on, but was not aware of the correct steps to activate the bed alarm. We then went on to do the RCA and found that their needed to be a more standardized hand off of patients with alarms on the shift to shift report. We developed and ordered a check list to go over during hand off report called a "Badge Buddy". We addressed it with the PCU [Progressive Care Unit] where the fall occurred and talked about it with the unit staff, and initiated some audits on the unit. We will do 30 audits per month for 4 months on high risk patients on that unit and verify the bed alarms are on and the fall risk protocol is followed. We talked to a company to possibly get more hi low beds, no arrangement has been made yet. The Action Plan was not taken across the board for falls, we just focused on the PCU, where it occurred, for the implementation of the action plan." The Quality Director revealed, "We are aware we have issues about falls. We recognized that with our fall policy, we have 2 standards of care going on at the same time. That does not conform with our fall policy." "This fall (11/5/17) brought it to light we have urgency with issues related to fall prevention, but not all falls are all of a sudden (related to system wide quality review), this was 1 large error. We have done a low aggressive review of that fall, NOT everything gets on the rush list." "This is clearly a house wide issue, not updating care plans, not using alarms consistently, side rail use is inconsistent and staff knowledge." "Yes we did identify this as a sentinel event (An unanticipated event in a healthcare setting resulting in death or serious physical injury to a patient.)"

The facility investigation/RCA identified issues related to the Patient 5's fall with significant injury. The facility followed up with the staff on the Progressive Care unit but failed to do a systemic analysis of the issue and failed to provide re-education to all nursing staff to prevent future falls with the potential for serious injury for those patients identified as high risk.

B. A review of Patient 8's medical record revealed that Patient 8 arrived to the hospital on 1/2/18 following being found down at work. The H&P identified the examination revealed a left basal intracerebral hemorrhage (hemorrhage CVA- bleeding in the brain causing a cerebral vascular accident) with right sided neglect (patients brain does not recognize the right side of the body) and aphasia (inability to speak). Patient 8 had a history of high blood pressure.

Review of the Nursing assessments related to Patient 8's Morse Fall Risk Score from 1/2/18 - 1/13/18 was 60 (indicating that the patient was high risk for falls-greater than 45), with the exception of 1/9/18 when the fall risk was identified as 35.

Review of Patient 8's charted fall interventions include:
-Yellow armband, non-skid socks and fall signage outside door of room for all assessments from 1/2/18-1/16/18.
-In addition to the above interventions the medical record charting also indicated alarms on the following days: 1/6/18-1/7/18 and 1/10/18-1/13/18. When Patient 8 was placed on Palliative Care on 1/13/18, the nursing staff did not continue to do the documentation of fall assessment scores and interventions.

The fall risk potential using the "Morse Fall Risk Assessment Tool", the tool assigns specific numbers to 6 items identified as risk factors for falls including; history of falling; diagnosis; ambulatory aid used; Intravenous line; transferring/gait and mental status. The score ranges 0-125 with the range of 0-24=low risk; 25-44=medium risk; 45+=high risk.)

Review of the "Fall Prevention Program and Risk for Injury Policy" last reviewed 6/2017 revealed: the facility Fall and Risk for Injury Interventions: High Risk for Fall Prevention Plan include: patient education; assess pt/family understanding of high-risk precautions; request teach-back; evaluate pt nutritional needs; consult dietary if warranted; use nutritional supplement if poor nutritional intake or frequent falls at home; colored armband, colored non-skid socks; when assistance is needed, us a gait belt; FOR PATIENTS THAT ARE CONFUSED, IMPULSIVE, OR CANNOT TEACH BACK FALL PREVENTION INSTRUCTIONS, RECOMMEND THE FOLLOWING: BED AND CHAIR ALARMS, SCHEDULED TOILETING, REMAIN WITH PATIENT ARMS LENGTH AND IN SIGHT WHILE TOILETING; FLOOR PAD AS NEEDED; EVALUATE NEED FOR LOW BED; campus specific fall signage outside the door of room; fall indicator signage inside room and visible to patient; consult with PT and OT if warranted; Evaluate need for assessing orthostatic blood pressure (blood pressure that falls when position changes) and evaluate the need for medication review.

During an observation and review of the Nursing Status Report sheet ran by the facility on 1/16/18 at 10:39 AM, Patient 8 had a Fall Risk score of 60. At 3:10 PM on 1/16/18 an observation of Patient 8 resting quietly in bed revealed, the patient had a yellow sign on door, had on a yellow bracelet and yellow slippers; the side rails were up by 3 and THE BED ALARM WAS NOT ACTIVATED.

C. A review of Patient 4's medical record revealed that Patient 4 arrived to the hospital on 1/12/18 from the nursing home where the patient resides. The H&P identified the examination revealed pneumonia (an infection of the lungs), sepsis (a systemic infection) and a history of dementia (mental confusion).

Review of the Nursing assessments related to Patient 4's Morse Fall Risk Score from 1/12/18 - 1/14/18 was 85 (indicating that the patient was high risk for falls-greater than 45), on 1/15/18 and 1/16/18 the fall risk score was identified at 100.

Review of the Physician Orders dated 1/15/18 at 2:00 PM, revealed, "Fall Precautions" indicated by a check mark in the box.

Review of Patient 4's charted fall interventions include:
-Yellow armband, non-skid socks, fall signage outside door of room, bed/chair alarms indicated.

During an observation and review of the Nursing Status Report sheet ran by the facility on 1/16/18 at 10:39 AM, Pt 4 had a Fall Risk score of 100. Observations of Patient 4 revealed:
-1/16/18 at 3:50 PM; Patient 4 was figiting with oxygen tubing while resting in bed. The patient had a yellow sign on door, had on a yellow bracelet and yellow slippers; the side rails were up by 3 and THE BED ALARM WAS NOT ACTIVATED. The observation was verified by the accompanying Risk Manager. The Risk Manager stated, "Sometimes I feel that the therapist go in and work with the patients and don't get the alarms back on."
-1/16/18 at 5:20 PM; Patient 4 figiting in bed revealed, the patient had a yellow sign on door, had on a yellow bracelet and yellow slippers; the side rails were up by 3 and THE BED ALARM WAS NOT ACTIVATED. The observation was verified by the accompanying Quality Director.
-1/17/18 at 2:55 PM; Patient 4 restless in bed revealed, the patient had a yellow sign on door, had on a yellow bracelet and yellow slippers; the side rails were up by 3 and THE BED ALARM WAS NOT ACTIVATED. The observation was verified by the accompanying RN Q.

D. A review of Patient 11's medical record revealed that Patient 11 arrived to the hospital on 1/14/18 with high blood sugar and diabetic ketoacidosis (A serious condition when the body builds up sugar and proteins (called ketones) in the blood from the body not having enough insulin therefore, breaking down body fats.) The medical record identified labored respirations, and fluid in the chest cavity which required a chest tube to be inserted to drain the fluid, history of below the knee amputation, liver cancer and increased weakness and lethargy.

Review of the Nursing assessments related to Patient 11's Morse Fall Risk Score from 1/14/18 - 1/21/18 ranged from 95 to 110 (indicating that the patient was high risk for falls-greater than 45). Review of Patient 11's charted fall interventions include:
-Yellow armband, non-skid socks, fall signage outside door of room, bed/chair alarms indicated.

Review of the 1/21/18 at 4:15 PM Fall Report revealed, (The spouse) assisted the patient to the bedside commode, while they were talking the patient slumped over and started to fall off the commode. (The spouse) reported that the patient was guided to the floor. When the staff arrived in the room the patient was found in a kneeling position on the floor.

An Interview on 1/23/18 at 4:30 PM with the Quality Director that had investigated the fall report revealed "The ALARMS WERE TO BE ON AND WERE NOT SOUNDING WHEN THE STAFF FOUND THE PATIENT ON THE FLOOR."



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E. Record review revealed Patient 10 was admitted on 1/11/18 for skin grafting surgery related to skin ulcers on the lower legs. On 1/16/17 at 4:25 PM the record identifies the patient's Morse fall risk score was 85 (greater than 45 is considered high fall risk). Risk factors identified included history of falls, diagnosis, ambulatory aid, Intravenous line (IV), weakness, and use of anticoagulation (medications used to prolong blood clotting), and recent surgical procedure. The patient was observed during safety rounds of high fall risk patients on 1/16/17 from 4:50 PM - 5:48 PM. Patient 10 was in bed with THE BED ALARM NOT ACTIVATED. Fall interventions to address fall risk in the patients Plan of Care were documented on 1/16/17 as yellow armband, yellow door sign, non skid socks, reorientation to person place and time, gait belt (belt used by staff to help support the patient with transfer/ambulation) and that the patient was located near the nurses station. Intervention for bed alarms/Tab (chair) alarm was blank, indicating they were not being provided. The section stating "Clinical Key handout on Fall Prevention given w [with]/ teach - back" is identified with "N" for No. The patient discharged to a nursing facility on 1/17/18.

F. Record review revealed Patient 2 was transferred to the hospital on 1/14/18. Diagnosis included acute encephalopathy (disease in which the functioning of the brain is affected), history of stroke, seizures, altered mental state, influenza A and cancer. The patient is non English Speaking. The patient record review of nursing assessments since admission documents the patient is confused and agitated at times. On 1/14/18 the patient had a sitter to maintain the patients safety. On 1/15/18 the patient was more cooperative and with family present a sitter was not provided. On 1/16/18 the patient required use of a sitter during the night for safety. Review of the Electronic Medication Administration Record (EMAR) noted the patient required the use of prn (as needed) Haldol 1 milligram IV at 8:02 AM on 1/16/18 for severe agitation. Haldol is an antipsychotic medication which can be used to decrease agitation/aggression.
The Morse fall score was done daily since admission and scored as high risk each day. The Plan of Care 1/14/17 included high fall risk and to be on interventions in the Fall Risk Protocol.
Observation on 1/16/18 at 3:55 PM found the patient confused and in bed with a family member present in the patient's room. The family said the patient gets very confused and thinks his sheets are on fire or that he has to go to work and tries to get up frequently. Family reported they try to stay when there is no sitter. The patient is on seizure precautions and has padded side rails. Patient 2 had yellow socks on. THE BED ALARM WAS NOT ACTIVATED. This was verified with the Quality Manager during the observation. On 1/16/17 at 5 PM the nurse documented the fall risk score was 75 (high). Documentation of interventions to address fall risk on 1/16/17 included yellow armband, yellow door sign, non skid socks. These were identified with a "Y" for yes beside the intervention. Additional interventions on the assessment included bed alarms/tab on, clinical key handout on fall prevention with teach-back, gait belt, remain with patient at arms length and in sight while toileting, hi-low bed with floor mats, frequent reminders to patient/family to call for help, encourage family to stay with patient, reoriented to person, place and time, patient located near nurses station and assess for functional ability were all left blank indicating these interventions were not being utilized. Additional observation on 1/17/18 at 3:58 PM found the patient in bed with the bed alarm on and family and sitter present in the room. Record review noted the patients fall risk on 1/17/18 remained high at 75.

Based on record reviews and review of facility policy and procedures, the facility failed to update the plan of care for 4 of 13 sampled patients (Patient's 5, 8, 4, and 1) when their condition changed, including those patients identified as being a high risk for falls. The total sample was 13. The facility census was 109.

Findings are:

A. A review of the medical record for Patient 5 revealed that Patient 5 arrived to the hospital on 10/29/17 for emergency services following 6 recent falls at home and after evaluation was admitted on 10/30/17.

The Death Summary dated 11/16/17 revealed that Patient 5's Discharge diagnoses included: 1) Death secondary to left hip fracture and subsequent complications; 2) Left hip fracture; 3)Multiple falls; 4) ACUTE INTRACRANIAL HEMORRHAGE SECONDARY TO FALL AND HEAD TRAUMA (bleeding in the brain following a fall at the hospital); 5) Severe acute toxic encephalopathy (sudden onset of confusion and/or delirium) this admission. Patient 5 had a left total hip replacement, following the surgery, Patient 5 developed significant delirium (confusion) and was restless. Patient 5 had thrashed around and subsequently developed a hematoma (a pocket of clotted blood in the tissue) which required going back into surgery for a washout (removal of hematoma) 2 days after the hip surgery. The patient then climbed out of bed 2 days later and fell and hit head sustaining an acute intracranial hemorrhage (bleeding in the brain) and dislocated the newly repaired hip. Patient 5 was moved to the ICU (Intensive Care Unit) and Patient 5's overall condition continued to decline. Ten days after the fall when Patient 5 sustained the acute intracranial hemorrhage, the patient was admitted to hospice care (end of life care) and passed away that day.

The medical record identified the Plan of Care for Patient 5 as: Impaired Mobility; Pain; Falls Risk; Knowledge deficient; Risk for altered Skin Integrity; and Risk for Infection.

The medical record lacked an individualized updated Plan of Care as Patient 5's condition changed including:
-Updated interventions initiated when assessed as a high fall risk-rails, sitters and alarms.
-Updated interventions initiated after the patient sustained a brain bleed following a fall from bed.
-Updated interventions initiated after the patient sustained a dislocation of the new hip prosthesis-knee immobilizer; abductor brace with specific setting; skin protection protocols while in the abductor brace.
-Updated interventions initiated after the patient returned from hip surgery with acute severe delirium.
-Updated care plan after the decision was made for end of life care.


B. A review of Patient 8's medical record revealed that Patient 8 arrived to the hospital on 1/2/18 following being found down at work. The H&P identified the examination revealed a left basal intracerebral hemorrhage (hemorrhage CVA- bleeding in the brain causing a cerebral vascular accident) with right sided neglect (patients brain does not recognize the right side of the body) and aphasia (inability to speak). Patient 8 had a history of high blood pressure.

The medical record identified the Plan of Care for Patient 8 as: Pain; Fall Risk; Alteration in Skin Integrity; Risk for Infection; Knowledge Deficit; Alteration in Tissue Profusion; Alteration in Mobility; and Alteration in Communication/Swallowing.

The medical record lacked an individualized updated Plan of Care as Patient's 8's condition changed including:
-Updated interventions initiated when assessed as a high fall risk-rails and alarms.
-Updated interventions initiated after the patient suffered pulmonary emboli (blood clots to the lungs) requiring surgical insertion of a IVC Filter (Inferior Vena Cava Filter- a filter to blood clots to the lungs).
-Updated interventions initiated after the patient required a nasal feeding tube, then to a failed attempt for the gastro-intestinal physicians to insert a feeding tube into the stomach, leading to a feeding tube being inserted in Interventional Radiation.
-Updated interventions initiated after the patient developed complications related to the feeding tube that was inserted into the patients stomach.
-Updated care plan after the decision was made for end of life care.

C. A review of Patient 4's medical record revealed that Patent 4 arrived to the hospital on 1/12/18 from the nursing home where the patient resides. The H&P identified the examination revealed pneumonia (an infection of the lungs), sepsis (a systemic infection) and a history of dementia (mental confusion).

The medical record identified the Plan of Care for Patient 4 as: Pain; Anxiety; Fall Risk; Alteration in Skin Integrity; Risk for Infection; Knowledge Deficit; Alteration in Nutrition; Alteration in Mentation-acute and chronic; Alteration in Fluid Imbalance; and Alteration in Respiratory Impairment.

The medical record lacked an individualized updated Plan of Care as Patient 4's condition changed including:
-Updated interventions initiated when assessed as a high fall risk and increased confusion-rails, sitters and alarms.

D. A review of Patient 1's medical record revealed that Patient 1 arrived to the hospital on 1/12/18 from the nursing home where the patient resides. The H&P identified the examination revealed pneumonia (an infection of the lungs); Acute hypoxic respiratory failure (sudden onset of low oxygen in the blood); and bilateral Pleural Effusion (Fluid in the layers of the tissue that lines the lungs).

The medical record identified the Plan of Care for Patient 1 as: Impaired Cardiac Function; Pain; Anxiety; Fall Risk; Alteration in Skin Integrity; Risk for Infection; Knowledge Deficit; Alteration in Nutrition; Fluid Imbalance; and Impaired Respiratory Function at the time of admission.

The medical record lacked an individualized updated Plan of Care as Patient 1's condition changed including:
-Updated interventions initiated when assessed as a high fall risk and increased confusion-rails, sitters and alarms.
-Updated interventions initiated after the patient was found to have bilateral pleural effusion requiring the insertion of chest tubes to drain the fluid
-Updated interventions initiated after the patient required blood pressure support with medications given intravenously after blood pressure became very low.
-Updated interventions initiated after the patient required a Bipap (machine to assist with effective breathing.)

E. Review of the policy and procedure for Plan of Care with last review date of 9/2017 revealed:
-All Patients will receive planned nursing care under the direct supervision of the RN. (Registered Nurse)
-Patient's plan of care goals are based on the nursing assessment which is realistic, measurable, and consistent with therapy prescribed.
-Actual and potential health problems identified as having the potential to be resolved through actions or interventions of the health care team will be identified on the patient's Interdisciplinary Plan of Care.
-The clinical care provided to patients will be based on established standards of patient care that reflect needs or problems as documented on the plan of care.
-The patient and/or family/significant other will be involved in the patient's care, as appropriate through inclusion in activities, which may include, but are not limited to, interviews, participation in care or education, care conferences, and discharge planning conferences.
-Nurses will review documentation by other disciplines and actively involve other members of the health care team in discussions about patient care problems/needs and in discharge plans.
-Discharge planning will begin upon admission and continue throughout the hospital stay.