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Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on document review and interviews the facility failed to ensure patients assigned to the direct care of a licensed practical nurse, were reassessed by a registered nurse after experiencing a fall. The failure was identified in 3 of 3 medical records (Patient #3, #7, and #9) where patients fell during their stay while assigned to the care of the licensed practical nurse (LPN). The facility also failed to ensure fall precaution measures were put in place for all patients documented as a high fall risk. The failure was identified in 4 of 11 patient medical records reviewed (Patient #3, #4, #7, and #9).The facility failed to ensure nursing staff evaluated and monitored patients' skin integrity, including wounds present on admission, surgical sites and wounds identified during the patient stay, in 6 of 10 medical records reviewed (Patients #3, #5, #7, #8, #9 and #10).

A-0398 Non-employee licensed nurses who are working in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel which occur within the responsibility of the nursing services. Based on observations, interviews and document reviews, the facility failed to ensure contracted nursing staff adhered to facility policies and procedures in 4 of 10 medical records reviewed (Patients #3, #8, #9 and #10).

Based on document review and interviews the facility failed to ensure patients assigned to the direct care of a licensed practical nurse, were reassessed by a registered nurse after experiencing a fall. The failure was identified in 3 of 3 medical records (Patient #3, #7, and #9) where patients fell during their stay while assigned to the care of the licensed practical nurse (LPN). The facility also failed to ensure fall precaution measures were put in place for all patients documented as a high fall risk. The failure was identified in 4 of 11 patient medical records reviewed (Patient #3, #4, #7, and #9).The facility failed to ensure nursing staff evaluated and monitored patients' skin integrity, including wounds present on admission, surgical sites and wounds identified during the patient stay, in 6 of 10 medical records reviewed (Patients #3, #5, #7, #8, #9 and #10).

Findings include:

Facility policy:

The policy, Interdisciplinary Fall Prevention, read the Fall Risk Program was a systematic screening process to determine the patients' risk for falling and to recommend interventions. The Hendrich II Fall Risk screening tool would be utilized to determine if there are existing factors that may affect the patient's fall risk. All patients are screened for fall risk to determine a score. A score of 0-4 was considered "low risk" versus a score of 5 or greater which was considered "high risk". "High risk" fall precautions included, but not limited to, the use of an alert wristband indicator, a "falling star" magnet indicator at the patient's room, or placing yellow socks on the patient.

The policy, Interdisciplinary Fall Prevention, read fall risks were rescreened each shift, and should the need arise, an in depth falls screen would occur if there was deterioration in the patient's medical/mental status and/or a fall occurred.

The policy, Interdisciplinary Fall Prevention read that after a patient experienced a fall, "post fall management" included assessing for injuries (i.e. abrasion, contusion, laceration, fracture, head injury), obtaining and recording vital signs (including checks in the supine, sit, and standing position), assessing for change in range of motion, recording circumstances of the fall in the medical record, and considering additional high fall risk interventions. Medical record documentation should also include assessments of the patient's neurological status, pain or discomfort, patient's response to fall, and a description of the event.

The Interdisciplinary Wound Prevention Assessment and Treatment policy read, every patient's skin integrity will be reassessed every 12 hours and/or as needed. Incisions, bruises, rashes, abrasions, skin tears, burns, moisture associated skin damage, incontinence associated dermatitis etc. will be noted and described. Daily findings will be recorded in the nursing notes.

1. The facility failed to ensure patients assigned to a licensed practical nurse, were reassessed by a registered nurse after the patient experienced a fall.

a. On 5/3/19 at 9:30 a.m., an interview was conducted with the nurse manager (Manager #2). According to Manager #2, the registered nurse was to reassess any patient for a change in their medical condition because it was outside the scope of practice for an LPN. Manager #2 stated the LPN was to report a patient's change of condition to the nursing house supervisor to obtain RN supervision, including reassessments of the patient after a fall. Manager #2 stated the RN was to reassess included whether the patient hit their head as a result of the fall, monitor the patient's neurological status (neuro checks), complete a head to toe physical assessments, and monitor vital signs.

b. On 5/2/19 at 2:47 p.m., an interview was conducted with registered nurse (RN #8). RN #8 stated the post-fall reassessment included reassessment of the patient's vital signs, pain level, signs and symptoms of injury, neurological status, and evaluate the cause of the patient's fall.

RN #8 stated it was important for the registered nurse to do post-fall reassessments because a fall was considered a change in the patient's condition. She said post-fall reassessments were completed to identify abnormal clinical changes in a timely manner.

RN #8 was unsure if an LPN's scope of practice allowed them to perform a patient's post-fall reassessment without the supervision of a registered nurse. Furthermore, RN #8 stated her leadership had not provided guidance into whether RN reassessments were required for patients' who fell while under the direct care of a licensed practical nurse (LPN).

c. On 5/1/19 at 1:54 p.m., an interview was conducted with an LPN (LPN #7). LPN #7 stated after a patient fell, the nursing assessment of a patient included a "head to toe" assessment, neuro checks every 15 minutes per orders, and monitor of vital signs.

LPN #7 said he was unsure if a registered nurse was required to complete a reassessments after a patient fell.

According to the interview, an RN was required to do the patient's initial nurse admission assessment. However, LPN #7 stated after the admission assessment the LPN assigned to the patient was responsible to complete all subsequent nurse assessments. LPN #7 stated he was unsure if an RN's supervision was required to perform reassessments when a patient experienced a possible change in condition to include a fall.

d. A document review was conducted of an Incident Report Form completed on 7/30/18 at 2:45 p.m. According to the document Patient #3 had a fall in the rehabilitation gym during group physical therapy. According to the report, the patient collapsed after the right lower extremity buckled and the patient landed on buttocks and fell backwards.

Record review was conducted for Patient #3, who was admitted on 7/23/18 and fell on 7/30/18. Review of LPN #7's nurse documentation on 7/30/18 found a lack of documented evidence the patient was reassessed by an RN after the fall.

e. Similar findings were identified upon review of Patient #9's medical record regarding a lack of an RN reassessment after the patient fell. According to the physician's progress note documented on 4/18/19 at 8:08 p.m., the patient "had a fall this evening", she fell in the bathroom and hit her head on the toilet, and "we will do neuro checks [for] two hours".

Review of the Neurological Observation Record, revealed the 15-minute neurological assessments were started at 5:30 p.m. and were not completed for the full two hours as stated in the physician progress note. There was a missing 15-minute assessment at 5:45 p.m., 7:00 p.m., 7:15 p.m., and 7:30 p.m. per the document.

Further review revealed LPN #7 completed the patient's post-fall reassessment and neuro checks without evidence of RN supervision/reassessment.

f. A record review was conducted for Patient #7, who sustained a fall on 3/12/19. Review of LPN #7's nurse documentation on 3/12/18 found a lack of documented evidence the patient was reassessed by an RN after the fall.

2. The facility failed to ensure the nursing staff consistently followed fall prevention measures per facility protocol, and patient needs.

a. A record review was conducted for Patient #3, admitted on 7/24/18. Review of the record identified a lack of fall prevention measures initiated after the patient was documented as a high fall risk.

As example, on 7/31/18 at 10:10 a.m., the Interdisciplinary Hendrich Fall Risk Screening Tool documented the patient as high risk for falls with a score of 9. However, there was no documented evidence high fall risk precautions were implemented.

According to the 7/31/18 1:55 p.m. daily nursing documentation there was also no documented evidence high fall risk precautions were initiated.

Review also found no evidence the patient's fall risk was reassessed after the patient experienced a fall on 7/30/18.

The findings were not compliant with the Interdisciplinary Fall Prevention policy.

b. On 5/3/19 at 9:30 a.m., an interview was conducted with the nurse manager (Manager #2) and the director of compliance (Director #1). Manager #1 stated the fall score could indicate if a patient was at low or high risk for falls, but nursing was responsible for using clinical judgement in order to implement safety alarms and fall prevention measures based on the needs of the patient. She stated once the patient was documented as high risk for falls, all high risk interventions should be attempted and documented.

Manager #2 reviewed the record for Patient #3. She stated the patient was documented as high risk for falls per the 7/31/18 Interdisciplinary Hendrich Fall Risk Screening Tool, but no documented evidence identified high risk fall interventions were put in place per policy.

Director #1 stated it was important for staff to follow fall prevention measures according to policy in order to prevent patients from experiencing falls or repeat falls.

c. A record review was conducted for Patient #4, admitted on 8/20/18. The record identified similar gaps in fall prevention measures documented after the patient was scored high risk according to the Hendrich Fall Risk Screening Tool.

As example, on 8/23/18 at 10:00 a.m. the patient was scored a 9 on the Safety/Risk-Fall Assessment, with 5 or greater considered high risk. Review of the assessment found no documented evidence high risk fall prevention measures were initiated per protocol, to include: door signage in place, yellow fall identification band indicator, or placing yellow socks on the patient.

On 8/24/18 at 8:00 a.m., the patient was scored a 9 on the Safety/Risk-Fall Assessment with no documented evidence high risk fall prevention measures were initiated per protocol

On 8/24/18 at 10:00 a.m., the patient was scored a 9 on the Safety/Risk-Fall Assessment with no documented evidence high risk fall prevention measures were initiated per protocol

On 8/25/18 at 10:00 a.m., the patient was scored a 9 on the Safety/Risk-Fall Assessment with no documented evidence high risk fall prevention measures were initiated per protocol

d. A record review was conducted for Patient #7, who sustained a fall in their room on 3/12/19. This record also identified gaps in fall prevention measures after the patient was scored a high risk according to the Fall Scale.

On 3/13/19 at 9:00 a.m., the Safety/Risk-Fall Assessment documented the patient as high risk for falls with a score of 13. There was no documented evidence high risk fall prevention measures were initiated per protocol

On 3/14/19 at 9:00 a.m., the Safety/Risk-Fall Assessment documented the patient as high risk for falls with a score of 11 with no documented evidence high fall risk prevention measures were initiated.

e. Record review was conducted for Patient #9, admitted on 4/11/19. Review of the record found a lack of documented evidence alarms were consistently initiated for the first 72 hours of the patient's admission.

For example on the 4/12/19 and 4/13/19 Daily Flowsheet Treatment Record, and general nursing documentation, safety fall alarm interventions were not documented as initiated.

f. A document review was conducted of the Nurses Meeting Notes for 3/20/19, which read all newly admitted patients would need fall safety alarms in place for the first 72 hours in order to prevent falls.

g. On 5/2/19 at 2:47 p.m., an interview was conducted with Director #1. She stated fall prevention alarms were to be utilized during the first 72 hours of admission for all patients. The staff were provided education on the new process in February/March during clinical orientation, staff meetings, and huddles. Director #1 stated fall prevention alarms were to be used on all patients for the first 72 hours, and as necessary after to continue preventing falls.


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3. The facility failed to ensure nursing staff evaluated and documented patients' skin integrity and wounds according to facility policy.

a. Review of Patient #3's medical record revealed a lack of evidence of daily dressing changes and skin integrity assessments.

According to the History and Physical (H & P), dated 7/23/19, Patient #3 was admitted for inpatient rehabilitation program on 7/23/19 after she had spine surgery on 7/20/18. Review of the H & P plan and goals, revealed the patient required daily dressing changes at the surgical incision site.

On 7/23/19 at 5:11 p.m., Patient #3's physician ordered the daily dressing changes.

Review of the Initial Wound Assessment documented on 7/24/18 at 7:00 a.m., revealed Patient #3 had a surgical wound to her lumbar region. According to the nursing documentation, the skin around the surgical incision was closed with normal skin color. The nurse documented the patient had scant sanguineous (bloody) drainage. Review of the image attached to the wound note, showed the patient's incision had staples.

Review of the nursing shift assessments, from 7/24/18 through 8/2/18, showed no evidence in 5 of 10 days, nursing staff completed the physician ordered daily dressing changes and visualized Patient #3's surgical site incision (7/26, 7/28, 7/29, 7/31 and 8/1). This was in contrast to policy which stated incisions, bruises, rashes, abrasions, skin tears, burns, moisture associated skin damage, incontinence associated dermatitis etc. will be noted and described.

Nursing shift assessments also revealed additional days where nursing staff noted Patient #3's surgical incision but did not document a description of the site. As example, on 7/25/19, Licensed Practical Nurse (LPN) #11 documented a shift assessment at 9:00 a.m. The LPN noted Patient #3 had a lower back surgical incision but she did not document if a dressing was in place. On the same day, the evening nurse documented at 8:30 p.m., the patient's dressing was changed, however, she did not document if the surgical site was without any signs and symptoms of infection, if the incision was approximated (two tissues surfaces close together) and if there was any drainage at the site.

On 8/3/19 Patient #3's surgical site staples were removed.

On 8/5/19 at 10:00 a.m., Patient #3's Registered Nurse (RN) documented the patient's steri strips (wound closure strips which can be used to close small wounds) were intact but there was no documentation which described the characteristics of the surgical incision.

i. On 5/2/19 at 3:29 p.m., an interview was conducted with RN #9. She stated surgical site care depended on the surgeon's or physician's orders. She said wound care was provided based on the order. RN #9 stated daily dressing changes meant the day nurse typically did the dressing changes, have the order and follow the order. She said surgical sites should be assessed for redness, warmth, drainage and signs and symptoms of infection.

RN #9 stated when she inspected a surgical site, she wanted to make sure the site was not getting worse, was well approximated and there was no dehiscing, swelling, redness and other signs and symptoms of infection.

RN #9 reviewed the nursing assessments for Patient #3 and confirmed the lack of dressing changes and visualization of the patient's surgical site.

b. Review of Patient #10's medical record was conducted.

According to the initial wound documentation, dated 4/24/19 at 3:00 p.m., Patient #10, upon admission, had a large left flank hematoma (a pooling of blood under the skin), a left forearm abrasion and right shin bruising. Review of Patient #10's medical record showed no skin/wound assessments documented by nursing staff on 4/25/19, 4/26/19, 4/27/19, 4/28/19 and 4/29/19.

According to the H & P dated, 4/24/19, the left flank hematoma was to be monitored.

i. On 5/2/19 at 2:06 p.m., RN #4 was interviewed. She was assigned to Patient #10's care on the day of the interview. RN #4 said the patient had a hematoma on his left side and bruising to his shin. She stated skin assessments should be completed every shift. RN #4 reviewed Patient #10's nursing assessments. She confirmed on 4/25/19 there was no evidence the night nurse assessed the patient's skin. She stated the nurse did not document anything. RN #4 was unable to find any evidence in the nursing assessments on 4/25/19, 4/26/19, 4/27/19, 4/28/19 and 4/29/19 which showed the patient's left side hematoma was monitored.

RN #4 stated nursing assessments were important to ensure if wounds which were present on admission, were monitored for improvement or if the wounds were getting worse.

c. Review of Patient #8's medical record was conducted. On 4/21/19 at 6:55 p.m., Patient #8's nurse documented a progress note after the patient fell. She documented Patient #8 fell to his left side without striking his head. RN #10 wrote the patient had a bruise to his right flank but was unsure if the bruising was sustained in the same fall.

Review of the nursing assessments from admission on 4/15/19 through 4/29/19, showed Patient #3's right flank bruising was only documented in the progress note dated 4/21/19 and in the nursing assessment documented by the night nurse, on 4/21/19 at 9:00 p.m.

On 4/30/19 at 4:50 p.m., Patient #8 and his wife were interviewed. Patient #8's wife stated after the patient's second fall on 4/21/19, she was told he had bruising on his right flank. She said she did not remember if the patient had the bruising before. Patient #8's wife showed the surveyor the patient's right flank which had a large bruise.

There was no evidence in Patient #8's medical record which indicated when the patient's bruise to his right flank appeared and how the wound occurred.

d. Review of Patient #9's medical record revealed on 4/18/19, LPN #7 documented a nursing note at 7:00 p.m. The note read, the patient was found sitting on the bathroom floor. LPN #7 documented the patient had swelling to her upper occiput (back of head) which measured two centimeters in diameter and four to five millimeters in height.

Review of the next nurse's note, documented at 8:30 p.m., showed no evidence the night nurse assessed the patient's head for swelling. From 4/19/19 through discharge, nursing documentation lacked evidence as to when the patient's swelling resolved.

Similar findings were found in Patient #5 and Patient #7's medical record.

e. On 5/3/19 at 9:31 a.m., an interview was conducted with the Director of Compliance (Director #1) and Nurse Manager (Manager) #2.

Manager #2 stated she was responsible for following up with patient wounds. She stated she was not aware both Patients #10 and #8 had hematomas. She stated, skin assessments were supposed to be done daily. She stated wound assessments were reflected in the nursing assessments documented in the medical record. Manager #2 said nursing staff were supposed to lay their eyes on the patient's skin each shift.

Manager #2 reviewed Patient #3's skin assessments. She stated according to the initial wound addendum, the surgical incision had staples and some scant drainage upon the initial assessment. She said wounds should be assessed for any redness, warmth, smell, drainage and monitored for infection. Manager #2 said nursing staff should make sure the incision was approximated.

She stated after reading Patient #3's skin assessments, it would tell me she did not have any issues with her surgical incision. However, Manager #2 then stated she would like to see more information documented. Manager #2 said she would like nursing staff to document if they actually looked at the wound and if there was a change with the incision. Manager #2 stated Patient #3's dressing needed to be changed every day so nursing staff could visualize the incision.
She stated then the team could track the incision and treat any concerns early if needed.

f. On 5/3/19 at 11:57 a.m., Director of Nursing (Director #3) was interviewed. She stated she started at the facility in October of 2018 and was responsible for the nursing department.

Director #3 stated "clearly" documentation was a point of contention at the facility. She said the nursing department was trying to improve and effectively immediately, there would be a process to review documentation. Director #3 stated if nursing staff did not document, the assessment or intervention was not considered done.

Based on observations, interviews and document reviews, the facility failed to ensure contracted nursing staff adhered to facility policies and procedures in 4 of 10 medical records reviewed (Patients #3, #8, #9 and #10).

Findings include:

Facility policy:

The Interdisciplinary Wound Prevention Assessment and Treatment policy read, every patient's skin integrity will be reassessed every 12 hours and/or as needed. Incisions, bruises, rashes, abrasions, skin tears, burns, moisture associated skin damage, incontinence associated dermatitis etc. will be noted and described. Daily findings will be recorded in the nursing notes.

1. The facility failed to ensure contracted nursing staff followed facility wound prevention and treatment policies and the fall prevention program.

a. Review of Patient #3's medical record was conducted.

According to the History and Physical (H & P), dated 7/23/19, Patient #3 was admitted to the inpatient rehabilitation program on 7/23/19 after she had spine surgery on 7/20/18. Review of the H & P plan and goals, revealed the patient required daily dressing changes at the surgical incision site.

On 7/23/19 at 5:11 p.m., Patient #3's physician ordered the daily dressing changes.

Review of the nursing shift assessments, from 7/24/18 through 8/2/18, showed no evidence in 5 of 10 days, nursing staff completed the physician ordered daily dressing changes and visualized Patient #3's surgical site incision (7/26, 7/28, 7/29, 7/31 and 8/1). This was in contrast to the policy which stated incisions, bruises, rashes, abrasions, skin tears, burns, moisture associated skin damage, incontinence associated dermatitis etc. will be noted and described.

Nursing shift assessments also revealed additional days where nursing staff noted Patient #3's surgical incision but did not document a description of the site. As example, on 7/25/19, Licensed Practical Nurse (LPN) #1, who was contracted labor, documented a shift assessment at 9:00 a.m. The LPN noted Patient #3 had a lower back surgical incision but she did not document if a dressing was in place.

On 7/28/18 and 7/29/18, both day and night shift nursing staff did not complete the physician order daily dressing change. There was also no evidence Patient #3's surgical incision was visualized and evaluated according to policy. Review of the treatment sheets for both days revealed the night RN responsible for Patient #3's care was a contracted nurse (RN #12). Similar findings were found on 8/7/19 at 7:10 p.m., where there was no evidence which described the skin integrity of Patient #3's surgical incision.

b. Review of Patient #10's medical record was conducted.

According to the initial wound documentation, dated 4/24/19 at 3:00 p.m., Patient #10, upon admission, had a large left flank hematoma (a pooling of blood under the skin), a left forearm abrasion and right shin bruising. Review of Patient #10's medical record showed no skin/wound assessments documented by nursing staff on 4/25/19, 4/26/19, 4/27/19, 4/28/19 and 4/29/19.

According to the H & P dated, 4/24/19, the left flank hematoma was to be monitored.

Review of the treatment sheets from 4/25/19 through 4/29/19, revealed four of the five days, Patient #10's assigned nursing staff were contracted labor (LPN #13 and RN #14).

c. Review of Patient #8's medical record was conducted. On 4/21/19 at 6:55 p.m., Patient #8's nurse documented a progress note after the patient fell. She documented Patient #8 fell to his left side without striking his head. RN #10 wrote the patient had a bruise to his right flank but was unsure if the bruising was sustained in the same fall.

Review of the nursing assessments from admission on 4/15/19 through 4/29/19, showed Patient #8's right flank bruising was only documented in the progress note dated 4/21/19 and in the nursing assessment documented by the night nurse, on 4/21/19 at 9:00 p.m.

On 4/30/19 at 4:50 p.m., Patient #8 and his wife were interviewed. Patient #8's wife stated after the patient's second fall on 4/21/19, she was told he had bruising on his right flank. She said she did not remember if the patient had the bruising before. Patient #8's wife showed the surveyor the patient's right flank which had a large bruise.

There was no evidence in Patient #8's medical record which indicated when the patient's bruise to his right flank appeared and how the wound occurred.

Review of the nursing assessments, after RN #10 identified Patient #8's right flank bruising, revealed on three days (4/25, 4/26 and 4/29), a contracted nurse (RN #15) was assigned to provide Patient #8 care. There was no evidence RN #15 followed policy.

d. Review of an email, dated 2/13/19, sent from the director of nursing (Director #3) to facility staff, revealed, an immediate change to the Fall program. According to the attached flyer, alarms were to be placed on patients for the first 72 hours after admission. The flyer also read, if a patient refused, nursing staff needed to document the refusal.

Review Patient #9's medical record revealed the patient was admitted on 4/11/19. According to Patient #9's initial nursing assessment documented on 4/11/19 at 2:30 p.m., Patient #9 had a history of falls at home. Nursing assessments documented on 4/11/19, 4/12/19 and 4/13/19 showed no evidence Patient #9 had alarms in place the first 72 hours after admission, which contradicted the email dated 2/13/19. On two of the three days, a contracted nurse was assigned to Patient #9's care.

e. On 5/3/19 at 11:57 a.m., an interview was conducted with Director #3 who stated she was responsible for the entire nursing department. She stated the facility did have eleven travelers but now have only seven. Director #3 stated her goal was to decrease the number on contracted nursing staff. Director #3 stated the house supervisors were supposed to follow up with the contracted staff to ensure they were following facility processes.

Director #3 stated "clearly" documentation was a point of contention at the facility. She said the nursing department was trying to improve and effectively immediately, there would be a process to review documentation. Director #3 stated if nursing staff did not document, the assessments or interventions were not considered done. She stated the facility needed to have more oversight of the contracted staff.