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Based on record review and interview, the hospital failed to ensure the grievance process was implemented according to regulations and hospital policy and procedure by failing to inform the complainant with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. Findings:

Review of Patient #3's medical record revealed Patient #3 was a 76-year-old female admitted to the hospital from a nursing home on 09/23/14 with the diagnoses of Psychosis, Advanced Dementia with Behavioral Disturbances, Agitation, Aggression, Combativeness, Hypertension, and Urinary Tract Infection.

Review of the hospital policy entitled Complaint/Grievance Process revealed, in part, the following:
Grievances are documented on a Grievance Report by the employee as soon as the grievance is received, and the report is immediately forwarded to the Department Manager/Supervisor. At a minimum, this must be completed by the end of the working shift.
Upon receiving the Grievance Report, the Department Manager/Supervisor:
a. Notifies the Risk Manager or designee
b. Notifies appropriate administrative personnel (Chief Clinical Officer and/or Chief Executive Officer
c. Reviews the Grievance Report as complete
d. Provides the Grievance Report to the Risk Manager or designee with a minimum of two working days.
Upon receiving the Grievance Report, the facility Risk Manager:
a. Reviews the Grievance Report
b. Identifies need for an "Immediate" or "Routine" response
c. Completes an Occurrence Referral Form and provides such to the appropriate party for documentation of further investigation.
A "Follow-up" response is provided to the patient (or designee) within five (5) working days of the event.

Review of the Grievance Reports from January, 2014, until current, revealed no documentation of a grievance or complaint documented for Patient #3.

Review of the monthly Incident/Occurrence Report forms for the months of April, May, June, July, August, and September, 2014, revealed no documentation of information regarding a grievance for Patient #3.

Review of a document entitled Psychiatrists Staffing/Treatment Team Progress Note/Family Meeting, completed by S21Physician on 09/29/14, revealed, in, part, "Meeting with Family (Husband and two daughters): They asked for a meeting because they were concerned about bruise on her forehead and her left arm, which are new findings." Further review of the document revealed "Recent or acute Physical problems/complaints: she sustained a large bruise on her forehead and also her right arm (family was notified and very upset about it)."

In an interview on 11/06/14 at 2:05 p.m., S2DON (Director of Nursing) verified she attended the meeting with Patient #3's family and S21Physician held on 09/29/14, and she had discussed with Patient #3's family the bruising on Patient #3's forehead and arms. S2DON confirmed she did not complete a Grievance Report form for Patient #3 because the situation had been discussed with the family during the above-referenced meeting. S2DON further confirmed she did not document any of the investigative process she conducted regarding the investigation of the grievance for Patient #3. When S2DON was asked what steps she had taken to conduct the grievance investigation, S2DON replied she had asked S22Physician to examine Patient #3; had spoken with various staff members to obtain information regarding Patient #3's bruising; and had asked S8RN (Registered Nurse) to contact Patient #3's family and inform the family a laboratory technician had drawn a blood sample from Patient #3's left arm a few days before, and Patient #3 had jerked her arm away while the laboratory technician was drawing the blood sample; the laboratory technician had informed S8RN that Patient #3 would likely have a "hematoma" to her left arm at the site where the blood sample was obtained because of Patient #3's behavior during the procedure. S2DON confirmed she considered the investigation completed when she asked S8RN to contact the family. S2DON also confirmed no written response regarding the grievance for Patient #3 was sent to Patient #3's family and a written response should have been sent to the family.

31048

Based on record review and interviews, the hospital failed to notify the patient's family/patient's representative of the patients' health status as evidenced by: (1) failure to notify family/patient's representative of patient falls for 3 ( #2, #4, #5) of 5 (#1-#5) patient records reviewed; (2) failure to notify family/patient's representative of unobserved injuries (bruising) for 1 (#3) of 5 (#1-#5) patient records reviewed. Findings:

(1) failure to notify family/patient's representative of patient falls for 3 ( #2, #4, #5) of 5 (#1- #5) patient records reviewed:

Patient #2
Review of the medical record for Patient #2 revealed she was a 26 year old female admitted to the hospital on 10/27/14 with an admitting diagnosis of Major Depressive Disorder, Recurrent and Severe. Her other diagnoses included Arthritis and Valvular Heart Disease.

Review of Patient #2's Nurses Daily Assessment notes, dated 10/27/14 at 8:30 p.m., revealed the following, in part: "patient had begun vomiting in the hall before making it to the bathroom, grabbed wall railing, and then fell on floor onto her buttocks." Further review revealed no documented evidence of staff notifying/attempting to notify the patient's family/representative that the patient had fallen.

Review of Patient #2's medical record revealed she had an emergency contact (mother-in- law) listed in her chart with a contact number.


Patient #4
Review of the medical record for Patient #4 revealed she was a 71 year old female admitted to the hospital on 9/13/14 with an admitting diagnosis of Psychosis. Her other diagnoses included CAD (Coronary Artery Disease), Hypertension, Hypothyroidism, DJD (Degenerative Joint Disease) and Schizophrenia.

Review of Patient #4's medical record revealed a consent, dated 9/15/14, signed by the patient, for release of information. The form listed three of the patient's daughters as family members authorized to receive information about the patient. Further review revealed the form contained contact information (phone numbers) for two of the patient's three daughters.

Review of Patient #4's medical record revealed the patient had fallen on 9/23/14 at 4:00 a.m. (sent to an area emergency room for evaluation and treatment); 9/24/14 at 1:30 a.m.(minor injuries sustained); 9/24/14 at 6:20 a.m. (minor injuries sustained); and 9/29/14 at 8:10 p.m. (minor injuries sustained). Further review of the Hospital Occurrence Reports describing each of the falls revealed no documented evidence of staff notifying/attempting to notify the patient's family after any of the falls.

Review of the Nurses Daily Shift Assessment Nurses Notes for the shifts correlating with the dates/times of the patient's falls revealed no documented evidence of staff notifying/attempting to notify the patient's family/representative, after any of the falls, that the patient had fallen.

Patient #5
Review of the medical record for Patient #5 revealed he was an 85 year old male admitted to the hospital on 9/18/14 with an admitting diagnosis of Delusional Disorder. His other diagnoses included Hypertension and Exacerbation of Psychosis.

Review of Patient # 5's medical record revealed the patient had an emergency contact/legal representative (daughter) listed with an accompanying contact number.

Review of the hospital's Patient/Visitor Hospital Occurrence Reports revealed Patient #5 had fallen, with minor injuries, on 9/22/14 at 6:35 a.m. Further review of the Hospital Occurrence Report describing the falls revealed no documented evidence of staff notifying/attempting to notify the patient's family after the fall.

Review of the Nurses Daily Shift Assessment Nurses Notes for the shift correlating with the date/time of the patient's fall revealed no documented evidence of staff notifying/attempting to notify the patient's family/representative that the patient had fallen.

In an interview on 11/5/14 at 2:23 p.m. with S9RN (Registered Nurse), he said the patient's family/representative would have been notified if a fall resulted in a hospitalization. S9RN explained if a patient's family had been involved he would also have called them if the patient had sustained an injury that had not resulted in transfer to the hospital for evaluation and treatment.

In an interview on 11/5/14 at 2:59 p.m. with S23RN, regarding Patient #4's fall on 9/24/14 at 1:30 a.m., he explained if he had called family to notify them of a fall, he would have documented that family /the patient's representative had been notified and would have noted who he had spoken to. He also explained if he had attempted to call a family and there had been no answer, or if the number had been disconnected/no longer in service, he would have documented that as well.

In an interview on 11/6/14 at 8:24 a.m. with S8RN, she said the patient's family/representative would have been notified that the patient had fallen if the patient had been sent to the hospital for evaluation/treatment. S8RN explained patients' family/representative would not have been notified of patient falls, even with injury, if the fall had not resulted in transfer to the hospital for evaluation/treatment.

In an interview on 11/6/14 at 2:08 p.m., with S2DON (Director of Nursing), she said the nursing staff should have been notifying the families/representatives of patients, who had fallen, after all falls, not just falls that had resulted in a transfer to the hospital for evaluation/treatment.


(2) failure to notify family/patient's representative of unobserved injuries (bruising) for 1 (#3) of 5 (#1-#5) patient records reviewed.

Patient #3

Review of Patient #3's medical record revealed Patient #3 was a 76-year-old female admitted to the hospital from a nursing home on 09/23/14 with the diagnoses of Psychosis, Advanced Dementia with Behavioral Disturbances, Agitation, Aggression, Combativeness, Hypertension, and Urinary Tract Infection.

Review of Patient #3's medical record revealed a document entitled Release of Information, which revealed, in part: "Consent to engage in verbal discussions: I, the undersigned patient, hereby authorize staff (hospital) to engage in verbal discussion with the following people:" (Patient #3's daughter) was identified as the authorized person for the purpose of disclosure.

Review of the Initial Nursing Assessment under the section, Skin Assessment, completed on 09/23/14 for Patient #3 revealed Patient #3 was assessed as having no skin abrasions, skin tears, burns, edema, hematoma, petechiae, bruises, decubitus, or rashes. Patient #3's skin assessment revealed Patient #3's skin was warm, dry, and intact with "various old scars intact."

Review of the initial History and Physical (H&P) documented by S22Physician on 09/24/14 revealed Patient #3 had no identified skin problems.

Review of the initial Psychiatric Evaluation/Admission note documented by S21Physician on 09/23/14 revealed under the section "Integument" (Skin): no acute skin problems evident or reported."

Review of Patient #3's medical record revealed nurses' notes from 09/23/14 through 09/25/14 did not contain any documentation of bruising noted on Patient #3.

Review of the nurse's note dated 09/26/14 at 2:00 a.m. revealed the following documentation by S9RN: "Large bruise noted on left forearm." Review of the nurse's note dated 09/27/14 for the 7 a.m. to 7 p.m. shift, under the section "Skin/Mucosa," revealed no documentation of bruising to patient by S14LPN (Licensed Practical Nurse). Review of the nurse's note dated 09/27/14 for the 7 p.m. to 7 a.m. shift, under the section "Skin/Mucosa," revealed "bruising to arms" documented by S10RN.

Review of Intake Information form revealed the family had not visited Patient #3 for the first few days, per S21Physician's recommendation, to allow Patient #3 time to adjust. The family visited Patient #3 on 09/27/14 and 09/28/14. During the initial visit by Patient #3's family, the family noted bruising to Patient #3's hands, upper and lower extremities, and her forehead.

Review of the Observational Checklist for 09/26/14, 7 p.m. to 7 a.m. revealed S15MHT (Mental Health Technician) was assigned to Patient #3.

In a telephone interview on 11/05/14 at 1:53 p.m., S15MHT indicated she had first noted a bruise on Patient #3's arm when she went to change her clothes during the night shift on 09/26/14. She also indicated S17MHT was working with her during the same shift, and was responsible for taking patients' vital signs. S15MHT further indicated S17MHT took Patient #3's vital signs during their shift, and S17MHT discussed with S15MHT she had noted a bruise on Patient #3's arm when she took Patient #3's vital signs on 09/26/14. S15MHT confirmed she reported the bruise noticed on Patient #3's arm to S9RN on 09/26/14. S15MHT indicated the only other bruises she noted during the Patient #3's hospital stay was after Patient #3's accident on 10/01/14, and the bruise was on the Patient #3's forehead. S15MHT confirmed she did not witness Patient #3 injuring herself or any staff injuring Patient #3, and she did not know how Patient #3's bruising occurred.

In a telephone interview on 11/05/14 at 2:10 p.m., S9RN indicated he remembered a significant bruise on Patient #3's left forearm the first night he took care of her on 09/26/14. He also indicated he noticed it on his assessment of Patient #3, but had not received in report any reason as to how the bruise had happened or any information from any staff about the bruise. S9RN further indicated he had not noticed a bruise on the patient's forehead until he received information from other staff that the family complained about a bruise on Patient #3's forehead. S9RN indicated Patient #3 had a posture in which her head and shoulders were slumped forward and resisted attempts for staff to assess her or render care. S9RN indicated Patient #3 also wore bangs over her forehead making it difficult to readily identify any injuries to her forehead. S9RN assessed Patient #3's forehead on 09/28/14 during the 7P-7A shift and documented a bruise on Patient #3's forehead, but did not notify the family because the family was responsible for bringing it to the staff's attention. He did not notify the family about the bruise on 09/26/14 to Patient #3's forearm because it did not happen during his care of the patient. S9RN verified he notifies the family and/or representative of patient injuries when patients are sent out of the hospital to the emergency department, or if a family was very involved in the patient's care, and there was written permission in the patient's chart to report information to indicated persons on the form.

In a telephone interview on 11/05/14 at 2:20 p.m., S17MHT indicated she did not witness any accidents, injuries, or falls with Patient #3, but upon her return to work on 10/01/14, she heard that the patient had fallen out of the bed, but did not know the date or time Patient #3 had reportedly fallen out of bed. S17MHT also indicated she noticed the bruise on Patient #3's forehead when she returned to work on 10/01/14, and Patient #3 was monitored more closely due to the fall and/or injury. S17MHT indicated Patient #3 was aggressive and combative with staff at times, and would pull away from staff and swing her arms at staff when staff attempted to care for her. S17MHT confirmed she did not witness Patient #3 injuring herself or any staff injuring Patient #3.

In a telephone interview on 11/05/14 at 2:35 p.m., S16MHT indicated when she returned to work on 9/30/14, she noted Patient #3 had a bruise on her forehead and she does not know or did not witness Patient #3 injuring herself or being injured by any staff, but Patient #3 was monitored more closely for falls precautions after the bruise on her forehead was identified. S16MHT further indicated she remembered the staff was trying to figure out how Patient #3 had injured herself, because the accident was not witnessed and the patient was on 15 minute checks.

In an interview on 11/06/14 at 10:11 a.m., S3ADON (Assistant Director of Nursing)confirmed there was no documentation in Patient #3's medical record that Patient #3's family had been notified of the Patient #3's bruising, and Patient #3's family should have been notified of any injuries.

31048

Based on interview and record review, the hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by failing to re-evaluate a patient's level of fall risk, after sustaining a fall, for 4 (#2, #3, #4, #5) of 5 (#1-#5) sampled patients reviewed.
Findings:

Patient #2
Review of the medical record for Patient #2 revealed she was a 26 year old female admitted to the hospital on 10/27/14 with an admitting diagnosis of Major Depressive Disorder, Recurrent and Severe. Her other diagnoses included Arthritis and Valvular Heart Disease.

Review of Patient #2's Nurses Daily Assessment notes, dated 10/27/14 at 8:30 p.m. revealed the following, in part: "patient had begun vomiting in the hall before making it to the bathroom, grabbed wall railing, and then fell on floor onto her buttocks."

Review of Patient #2's medical record revealed her level of fall risk had not been re-evaluated after she had fallen on 10/27/14.

Review of the Patient Precautions List for 11/5/14 revealed Patient #2 was on fall precautions.

Patient #3

Review of Patient #3's medical record revealed Patient #3 was a 76-year-old female admitted to the hospital from a nursing home on 09/23/14 with the diagnoses of Psychosis, Advanced Dementia with Behavioral Disturbances, Agitation, Aggression, Combativeness, Hypertension, and Urinary Tract Infection.

Review of the Initial Nursing Assessment for Patient #3 completed on 09/23/14 revealed Patient #3 was assessed to be a "Moderate" fall risk category.

Review of Patient #3's nurses' notes documentation on 10/01/14 at 5:30 a.m., revealed, in part, "Called to room my MHT (Mental Health Technician), patient found sitting on floor on behind-scooting self backwards and is anxious and very confused. She is resistant and defiant...."

Further review of Patient #3's medical record revealed an up-dated "Falls Risk Assessment" Form was not completed for Patient #3 after the initial one on 09/23/14 (admit date).

In an interview on 11/06/14 at 10:11 a.m., S3ADON confirmed Patient #3 had not had an up-dated "Falls Risk Assessment" to re-evaluate Patient #3's risk category for falls since the initial one completed on 09/23/14, and Patient #3 should have had a re-evaluation completed.

Patient #4
Review of the medical record for Patient #4 revealed she was a 71 year old female admitted to the hospital on 9/13/14 with an admitting diagnosis of Psychosis. Her other diagnoses included CAD (Coronary Artery Disease), Hypertension, Hypothyroidism, DJD (Degenerative Joint Disease) and Schizophrenia.

Review of the hospital document for Patient #4, titled Nursing Assessment, revealed it had been completed on 9/13/14 at 1:40 a.m. Further review revealed Patient #4 had obtained a score indicative of low fall risk (0-5). No Interventions needed.

Review of Patient #4's Observational Check sheets, dated 9/20/14-10/1/14, revealed the patient's observational level was listed as monitoring every 15 minutes. Further review revealed the documented reason for the level of observation was fall precautions and acting out behaviors.

Review of Patient #4's medical record revealed no re-assessment of the patient's level of fall risk (except initially, on admit) to evaluate whether her level of risk had increased after she had fallen on 9/23/14 at 4:00 a.m. (sent to an area emergency room for evaluation and treatment); 9/24/14 at 1:30 a.m. (minor injuries sustained); 9/24/14 at 6:20 a.m. (minor injuries sustained); and 9/29/14 at 8:10 p.m.(minor injuries sustained).

Patient #5
Review of the medical record for Patient #5 revealed he was an 85 year old male admitted to the hospital on 9/18/14 with an admitting diagnosis of Delusional Disorder. His other diagnoses included Hypertension and Exacerbation of Psychosis.

Review of the hospital's Patient/Visitor Hospital Occurrence Reports revealed Patient #5 had fallen, with minor injuries, on 9/22/14 at 6:35 a.m.

Review of Patient #5's medical record revealed no re-assessment of the patient's level of fall risk (except initially, on admit) to evaluate whether his level of risk had increased after he had fallen on 9/22/14 at 6:35 a.m.

In an interview on 11/6/14 at 8:24 a.m. with S8RN, she said as far as she knows, fall risk assessments (which determine levels of fall risk) were not performed after each fall to determine if the patient had progressed to the next level of fall risk/level of interventions. S8RN confirmed different levels of fall risk required initiation of new interventions.

In an interview on 11/6/14 at 10:31 a.m., with S3ADON, he said fall risk assessment, which determined level of fall risk, should have been performed after each fall to determine whether the patient's risk had increased to the next level, requiring new interventions.

In an interview on 11/6/14 at 2:08 pm, with S2DON, she said that level of fall risk assessment, which would have determined whether a patient had advanced to a higher level of fall risk, should have been performed after each patient fall. S2DON agreed progression to a higher level of fall risk would have involved a change in fall prevention interventions.

Based on interview and record review, the hospital failed to ensure the nursing staff developed and kept current an individualized nursing care plan for each patient as evidenced by:
1)Failing to include fall risk as a problem on the patient's Interdisciplinary Plan of Care for patients who had been identified, upon admit, as being at risk for falls for 3 (#1, #3, #5) of 5 (#1-#5) patients sampled.
2)Failing to initiate fall risk as an identified problem on the patient's Interdisciplinary Plan of Care, after the patient had fallen, for 3 (#2, #4, #5) of 5 (#1-#5) patients sampled.
Findings:

Review of the policy titled Fall Precautions, Policy 8.27; Section: Environment of Care, revealed the following in part:
Policy:
It is the policy of the hospital to implement, as a matter of routine, precautionary measures designed to minimize the risk of patient falls.
Purpose: To define those measures which will be implemented to prevent patient falls.
Procedure:
6) Falls precautions will be implemented for those patients who are assessed to be at risk for falling. Behaviors indicating such risk include, but are not limited to:
a. dizziness; b. unsteady gait; c. lethargy; d. hypotension; and/or; e. history of falls.
7) Falls Precautions will include: a. increased observation of the patient at the frequency specified by the physician or nursing orders; b. star placed on patients door; c. assisting the patient in performing ADLs (activities of daily living); d. assisting the patient in ambulating, as needed; e. encouraging patient to limit fluids after 9:00 p.m.; f. encouraging patient to void at bedtime; g. verbally reminding patient to seek staff assistance if they need to get out of bed throughout the night; h. Patient will be assigned to a bed, closer to the nurses station, if possible; i. asking patients who are found to be awake during night time rounds as to their need for assistance, use of the bathroom, and/or reason for being awake.
8) Continued need for Falls Precautions will be evaluated on a daily basis.
9) Documentation of falls precautions procedures in the medical record should include: a. description of patient's behaviors/status; b. interventions implemented; c. patient response to interventions; d. level of observation and frequency of staff contact; and; e. maintenance of protocol until discontinued by the attending psychiatrist.

Review of the hospital's Risk for Falls Assessment Tool on the Initial Nursing Assessment form (completed upon admit) revealed the following categories and their accompanying scores:
Risk factors:
Age: under 60 years: 0; 60-70 years: 1; 71-81 years: 2; Over 80 years: 3
Gender: Male: 0; Female: 1
Mental Status: Oriented x (times) 3: 0; Occasional confusion/distraction: 1; Restless, confused: 2; Sedated, restless, agitated/confused: 3
Gait/Balance: Steady Gait: 0; Balance problems: 1; Poor Muscle Coordination: 2; Jerking, unstable, uses assistive devices: 3
Medications: No increase medications: 0; 1-2 increase risk medications: 1; 3-4 increased risk medications: 2; 5 or greater increased risk medications: 3
History of falls: No history of falls: 0; Fallen 1 x last 6 months: 1; 1-2 falls last 3-6 months: 2; 3 or more falls last 3 months: 3
Vision Status: Adequate with or without glasses: 0; Inadequate with or without glasses: 2; Legally blind: 3
Total Points: Low Risk: 5; Moderate Risk: 6-10; High Risk: 11-20.

1)Failing to include fall risk as problem on the patient's Interdisciplinary Plan of Care for patients who had been identified, upon admit, as being at risk for falls for 3 (#1, #3, #5) of 5 (#1-#5) patients sampled.

Patient #1
Review of the medical record for Patient #1 revealed she was a 77 year old female admitted to the hospital on 11/5/14 with the admitting diagnosis of Dementia with Behavior Disturbance. Her other diagnoses included Hypertension and Unstable Mood.

Review of the hospital document for Patient #1 titled Nursing Assessment revealed it had been completed on 11/5/14 at 2:15 a.m. Further review revealed Patient #1 had obtained a score indicative of moderate risk (6-10). Interventions to be initiated with a moderate fall risk were as follows: 1.Educated pt. (patient) on safe ambulation including asking for assistance when needed; 2. MHT (Mental Health Technician) notified to assist pt .getting in/out of wheelchair, bed, to and from bathroom; 3. MHT notified to offer bathroom q (every) 2 hours; 4. Encouraged proper use of assistive devices.

Review of Patient #1's Observational Check sheets revealed the patient's observational level was listed as monitoring every 15 minutes. Further review revealed the documented reason for the level of observation was fall precautions and acting out behaviors.

Review of Patient #1's Nurses Daily Assessment notes, dated 11/5/14 at 10:00 p.m. revealed the patient's balance problems were listed as a fall risk.

Review of the document titled Interdisciplinary Patient Plan of Care for Patient #1 revealed fall risk had not been included as an identified problem in the patient's plan of care.

Patient #3

Review of Patient #3's medical record revealed Patient #3 was a 76-year-old female admitted to the hospital from a nursing home on 09/23/14 with the diagnoses of Psychosis, Advanced Dementia with Behavioral Disturbances, Agitation, Aggression, Combativeness, Hypertension, and Urinary Tract Infection.

Review of the Initial Nursing Assessment for Patient #3 completed on 09/23/14 revealed Patient #3 was assessed to be a "Moderate" fall risk.

Review of Patient #3's nurses' notes documentation on 10/01/14 at 5:30 a.m., revealed, in part, "Called to room my MHT (Mental Health Technician), patient found sitting on floor on behind-scooting self backwards and is anxious and very confused. She is resistant and defiant...."

Review of the form entitled "Multidisciplinary Integrated Assessment, Preliminary Treatment" form completed by the nursing staff revealed the following, in part: Initial Problem List: 1. Agitation; 2. Confusion; 3. Skin Integrity; and 4. Safety (Fall Risk). There were no dates assigned to the items listed under the Initial Problem List. Further Review of the form revealed the following, in part: Nursing Care Plan: Problem #1, Cognition Altered, initiated on 09/23/14; Problem #2, Behavior Disturbance, initiated on 09/23/14; Problem #3, Skin Integrity, initiated on 10/02/14; and Problem #4, Safety (Fall Risk), initiated on 10/02/14.

Review of the Master Treatment Plan revealed Problem #4, Safety (Fall Risk) was not implemented until 10/02/14.

In an interview on 11/06/14 at 10:11 a.m., S3ADON verified Patient #3 was not placed on "Fall Precautions" until 10/02/14. S3ADON confirmed Patient #3 was assessed as a "Moderate" risk for falls on 09/23/14 (admit date), and fall precautions should have been implemented for Patient #3 on 09/23/14.

Patient #5
Review of the medical record for Patient #5 revealed he was an 85 year old male admitted to the hospital on 9/18/14 with an admitting diagnosis of Delusional Disorder. His other diagnoses included Hypertension and exacerbation of Psychosis.

Review of the hospital document for Patient #5 titled Nursing Assessment revealed it had been completed on 9/18/14 at 12:30 p.m. Further review revealed Patient #5 had obtained a score of Moderate Risk (6-10). Interventions to be initiated with moderate fall risk were as follows: 1.Educated pt. (patient) on safe ambulation including asking for assistance when needed; 2. MHT (Mental Health Technician) notified to assist pt .getting in/out of wheelchair, bed, to and from bathroom; 3. MHT notified to offer bathroom q (every) 2 hours; 4. Encouraged proper use of assistive devices.

Review of Patient #5's Observational Check sheets revealed the patient's observational level was listed as monitoring every 15 minutes. Further review revealed the documented reason for the level of observation was fall precautions and behaviors.

Review of the document titled Interdisciplinary Patient Plan of Care for Patient #5, initiated 9/18/14, revealed fall risk had not been included as an identified problem in the patient's plan of care.

In an interview on 11/6/14 at 10:31 a.m., with S3ADON, he confirmed patients assessed as at risk for falls, on admit, should have been care planned for fall risk.

In an interview on 11/6/14 at 2:08 p.m., with S2DON, she said fall risk, identified upon admit, should have been addressed in the patient's care plans.


2) Failing to initiate fall risk as an identified problem on the patient's Interdisciplinary Plan of Care, after the patient had fallen, for 3 (#2, #4, #5) of 5 (#1-#5) patients sampled.

Patient #2
Review of the medical record for Patient #2 revealed she was a 26 year old female admitted to the hospital on 10/27/14 with an admitting diagnosis of Major Depressive Disorder, Recurrent and Severe. Her other diagnoses included Arthritis and Valvular Heart Disease.

Review of the hospital document for Patient #2, titled Nursing Assessment, revealed it had been completed on 10/27/14. Further review revealed Patient #2 had obtained a score indicative of low fall risk (0-5). No Interventions needed.

Review of Patient #2's Observational Check sheets, dated 10/27/14, revealed the patient's observational level was listed as monitoring every 15 minutes. Further review revealed the documented reason for the level of observation was fall precautions and acting out behaviors.

Review of Patient #2's Nurses Daily Assessment notes, dated 10/27/14 at 8:30 p.m. revealed the following, in part: "patient had begun vomiting in the hall before making it to the bathroom, grabbed wall railing, and then fell on floor onto her buttocks."

Review of the document titled Interdisciplinary Patient Plan of Care for Patient #2 revealed fall risk had not been included as an identified problem in the patient's plan of care after she had fallen on 10/27/14.

Review of the Patient Precautions List for 11/5/14 revealed Patient #2 was on fall precautions.

On 11/5/14 at 10:00 a.m., an observation was made of Patient #2 in the commons area. She was being monitored by a MHT for fall and behavioral precautions. She was frail looking and her hands were noted to have tremors. Patient #2 walked slowly and her balance was slightly unsteady.

Patient #4
Review of the medical record for Patient #4 revealed she was a 71 year old female admitted to the hospital on 9/13/14 with an admitting diagnosis of Psychosis. Her other diagnoses included CAD (Coronary Artery Disease), Hypertension, Hypothyroidism, DJD (Degenerative Joint Disease) and Schizophrenia.

Review of the hospital document for Patient #4, titled Nursing Assessment, revealed it had been completed on 9/13/14 at 1:40 a.m. Further review revealed Patient #4 had obtained a score indicative of low fall risk (0-5). No Interventions needed.

Review of Patient #4's medical record revealed no re-assessment of the patient's level of fall risk (except initially, on admit) to evaluate whether her level of risk had increased after she had fallen on 9/23/14 at 4:00 a.m. (sent to an area emergency room for evaluation and treatment); 9/24/14 at 1:30 a.m. (minor injuries sustained); and 9/24/14 at 6:20 a.m. (minor injuries sustained).

Review of Patient #4's Observational Check sheets, dated 9/20/14-10/1/14, revealed the patient's observational level was listed as monitoring every 15 minutes. Further review revealed the documented reason for the level of observation was fall precautions and acting out behaviors.

Review of Patient #4's Weekly Treatment Plan Updates with Physician Certification revealed the following entries:
9/18/14: Changes in Treatment Plan as directed by Multidisciplinary Team Conference
(Problems as identified on Master Treatment Plan):
1. Psychosis
2. Hypertension
New goals: blank; New interventions: blank
9/25/14: Changes in Treatment Plan as directed by Multidisciplinary Team Conference
(Problems as identified on Master Treatment Plan):
1. Psychosis
2. Hypertension
New goals: blank; New interventions: blank
Further review revealed Patient fall risk was not incorporated into the patient's plan of care during this treatment plan update meeting.

Patient #5
Review of the medical record for Patient #5 revealed he was an 85 year old male admitted to the hospital on 9/18/14 with an admitting diagnosis of Delusional Disorder. His other diagnoses included Hypertension and Exacerbation of Psychosis.

Review of the hospital's Patient/Visitor Hospital Occurrence Reports revealed Patient #5 had fallen, with minor injuries, on 9/22/14 at 6:35 a.m.

Review of Patient #5's medical record revealed no re-assessment of the patient's level of fall risk (except initially, on admit) to evaluate whether his level of risk had increased after he had fallen on 9/22/14 at 6:35 a.m.

Review of the document titled Interdisciplinary Patient Plan of Care for Patient #5, initiated 9/18/14, revealed fall risk had not been included as an identified problem in the patient's plan of care after he had fallen on 9/22/14 at 6:35 a.m.

In an interview on 11/6/14 at 8:24 a.m. with S8RN, she said as far as she knows, fall risk assessments (which determine levels of fall risk) were not performed after each fall to determine if the patient had progressed to the next level of fall risk/level of interventions. S8RN confirmed different levels of fall risk required initiation of new interventions. S8RN also confirmed care plans should have been updated after each patient fall.

In an interview on 11/6/14 at 10:31 a.m., with S3ADON, he confirmed patient care plans should have been updated after each fall. S3ADON said the fall risk assessment (which determined level of fall risk) should have been performed after each fall to determine whether the patient's risk had increased to the next level.

In an interview on 11/6/14 at 2:08 p.m., with S2DON, she confirmed patient care plans should have been updated after each fall. She also agreed that level of fall risk assessment, determining whether patient had advanced to a higher level of fall risk requiring a change in interventions, should have been performed after each patient fall.



31048

Based on record review and interviews, the hospital failed to document a patient's family was notified of patient's discharge from the hospital on the day the patient was discharged from the hospital. Findings:

Review of Patient #3's medical record revealed Patient #3 was a 76-year-old female admitted to the hospital from a nursing home on 09/23/14 with the diagnoses of Psychosis, Advanced Dementia with Behavioral Disturbances, Agitation, Aggression, Combativeness, Hypertension, and Urinary Tract Infection.

Review of Patient #3's physician orders revealed a physician's verbal order from S21Physician was taken by S7RNCoordinator on 10/03/14 at 10:10 a.m. Further review of the medical record revealed Patient #3's assigned social worker was S18SW.

A review of the documents entitled, Discharge Procedure (completed by S13RN on 10/03/14 at 12:00 p.m.); Continuing Care/Discharge Planning, page one, (completed by S18SW on 10/03/14); Continuing Care/Discharge Planning, pages 2 and 3, (completed by S13RN); Discharge Summary (completed by S13RN on 10/03/14 at 12:00 p.m.); nurses' daily note sheets; nurses' narrative note sheets; physician progress notes; and social services notes revealed no documentation Patient #3's family was notified that Patient #3 was discharged on 10/03/14 from the hospital back to the nursing home. A review of Patient #3's entire medical record revealed no documentation Patient #3's family was notified of Patient #3's impending discharge or actual discharge on the day Patient #3 was discharged from the hospital back to the nursing home.

In an interview on 11/06/14 at 10:11 a.m., S3ADON (Assistant Director of Nursing) indicated if patients' discharges are pre-planned (physician discharge orders written on the day before a patient is actually to be discharged), the pre-planned discharge process begins with S7RN(Registered Nurse) Coordinator (Admit/Discharge) and S20SW (Social Worker, Admit/Discharge Coordinator). Each respective discipline starts the process for discharging a patient by obtaining and preparing documents needed to facilitate a patient's discharge. S7RN facilities the medical aspects of a patient's discharge (medications), and S20SW facilitates discharge issues such as placement, follow-up appointments, and coordination with family members for patients' discharge issues. S3ADON also indicated either of the intake/discharge facilitators can notify family members of a pending discharge, but it is the social worker's role to coordinate discharge issues with family members. S3ADON also indicated if a discharge is not pre-planned (physician orders for discharge are written on the day of discharge), and/or a patient is discharged "after hours," then the unit nurses initiate the facilitation of the patient's discharge.

S3ADON confirmed any communication regarding discharge activities should be documented in the patient's medical record. S3DON also confirmed he did not see any documentation in Patient #3's entire medical record that Patient #3's family was notified of Patient #3's discharge, and the social worker should have notified the family of the Patient #3's discharge.

In a telephone interview on 11/06/14 at 11:40 a.m., Armorial confirmed she did not notify Patient #3's family of Patient #3's discharge, and that S18SW or S20SW should have notified Patient #3's family of the patient's discharge from the hospital.

In an interview on 11/06/14 at 10:53 a.m., S18SW indicated she had contacted Patient #3's daughter to inform her of Patient #3's discharge from the hospital back to the nursing home. S18SW confirmed there was no documentation in the medical record that Patient #3's family was notified of Patient #3's discharge from the hospital.

In an interview on 11/06/14 at 11:45 a.m., S20SW indicated she coordinates discharge orders/plans with the patient's assigned social worker on the unit, and one of them will call the family members to inform them of a patient's discharge. S20SW also indicated she did not remember if she had called Patient #3's family, but if she had, she would have documented it in the patient's medical record. S20SW confirmed she did not find any documentation Patient #3's family was notified of Patient #3's discharge from the hospital.

Based on interview and record review, the hospital failed to ensure the nursing staff developed and kept current an individualized nursing care plan for each patient as evidenced by:
1)Failing to include fall risk as a problem on the patient's Interdisciplinary Plan of Care for patients who had been identified, upon admit, as being at risk for falls for 3 (#1, #3, #5) of 5 (#1-#5) patients sampled.
2)Failing to initiate fall risk as an identified problem on the patient's Interdisciplinary Plan of Care, after the patient had fallen, for 3 (#2, #4, #5) of 5 (#1-#5) patients sampled.
Findings:

Review of the policy titled Fall Precautions, Policy 8.27; Section: Environment of Care, revealed the following in part:
Policy:
It is the policy of the hospital to implement, as a matter of routine, precautionary measures designed to minimize the risk of patient falls.
Purpose: To define those measures which will be implemented to prevent patient falls.
Procedure:
6) Falls precautions will be implemented for those patients who are assessed to be at risk for falling. Behaviors indicating such risk include, but are not limited to:
a. dizziness; b. unsteady gait; c. lethargy; d. hypotension; and/or; e. history of falls.
7) Falls Precautions will include: a. increased observation of the patient at the frequency specified by the physician or nursing orders; b. star placed on patients door; c. assisting the patient in performing ADLs (activities of daily living); d. assisting the patient in ambulating, as needed; e. encouraging patient to limit fluids after 9:00 p.m.; f. encouraging patient to void at bedtime; g. verbally reminding patient to seek staff assistance if they need to get out of bed throughout the night; h. Patient will be assigned to a bed, closer to the nurses station, if possible; i. asking patients who are found to be awake during night time rounds as to their need for assistance, use of the bathroom, and/or reason for being awake.
8) Continued need for Falls Precautions will be evaluated on a daily basis.
9) Documentation of falls precautions procedures in the medical record should include: a. description of patient's behaviors/status; b. interventions implemented; c. patient response to interventions; d. level of observation and frequency of staff contact; and; e. maintenance of protocol until discontinued by the attending psychiatrist.

Review of the hospital's Risk for Falls Assessment Tool on the Initial Nursing Assessment form (completed upon admit) revealed the following categories and their accompanying scores:
Risk factors:
Age: under 60 years: 0; 60-70 years: 1; 71-81 years: 2; Over 80 years: 3
Gender: Male: 0; Female: 1
Mental Status: Oriented x (times) 3: 0; Occasional confusion/distraction: 1; Restless, confused: 2; Sedated, restless, agitated/confused: 3
Gait/Balance: Steady Gait: 0; Balance problems: 1; Poor Muscle Coordination: 2; Jerking, unstable, uses assistive devices: 3
Medications: No increase medications: 0; 1-2 increase risk medications: 1; 3-4 increased risk medications: 2; 5 or greater increased risk medications: 3
History of falls: No history of falls: 0; Fallen 1 x last 6 months: 1; 1-2 falls last 3-6 months: 2; 3 or more falls last 3 months: 3
Vision Status: Adequate with or without glasses: 0; Inadequate with or without glasses: 2; Legally blind: 3
Total Points: Low Risk: 5; Moderate Risk: 6-10; High Risk: 11-20.

1)Failing to include fall risk as problem on the patient's Interdisciplinary Plan of Care for patients who had been identified, upon admit, as being at risk for falls for 3 (#1, #3, #5) of 5 (#1-#5) patients sampled.

Patient #1
Review of the medical record for Patient #1 revealed she was a 77 year old female admitted to the hospital on 11/5/14 with the admitting diagnosis of Dementia with Behavior Disturbance. Her other diagnoses included Hypertension and Unstable Mood.

Review of the hospital document for Patient #1 titled Nursing Assessment revealed it had been completed on 11/5/14 at 2:15 a.m. Further review revealed Patient #1 had obtained a score indicative of moderate risk (6-10). Interventions to be initiated with a moderate fall risk were as follows: 1.Educated pt. (patient) on safe ambulation including asking for assistance when needed; 2. MHT (Mental Health Technician) notified to assist pt .getting in/out of wheelchair, bed, to and from bathroom; 3. MHT notified to offer bathroom q (every) 2 hours; 4. Encouraged proper use of assistive devices.

Review of Patient #1's Observational Check sheets revealed the patient's observational level was listed as monitoring every 15 minutes. Further review revealed the documented reason for the level of observation was fall precautions and acting out behaviors.

Review of Patient #1's Nurses Daily Assessment notes, dated 11/5/14 at 10:00 p.m. revealed the patient's balance problems were listed as a fall risk.

Review of the document titled Interdisciplinary Patient Plan of Care for Patient #1 revealed fall risk had not been included as an identified problem in the patient's plan of care.

Patient #3

Review of Patient #3's medical record revealed Patient #3 was a 76-year-old female admitted to the hospital from a nursing home on 09/23/14 with the diagnoses of Psychosis, Advanced Dementia with Behavioral Disturbances, Agitation, Aggression, Combativeness, Hypertension, and Urinary Tract Infection.

Review of the Initial Nursing Assessment for Patient #3 completed on 09/23/14 revealed Patient #3 was assessed to be a "Moderate" fall risk.

Review of Patient #3's nurses' notes documentation on 10/01/14 at 5:30 a.m., revealed, in part, "Called to room my MHT (Mental Health Technician), patient found sitting on floor on behind-scooting self backwards and is anxious and very confused. She is resistant and defiant...."

Review of the form entitled "Multidisciplinary Integrated Assessment, Preliminary Treatment" form completed by the nursing staff revealed the following, in part: Initial Problem List: 1. Agitation; 2. Confusion; 3. Skin Integrity; and 4. Safety (Fall Risk). There were no dates assigned to the items listed under the Initial Problem List. Further Review of the form revealed the following, in part: Nursing Care Plan: Problem #1, Cognition Altered, initiated on 09/23/14; Problem #2, Behavior Disturbance, initiated on 09/23/14; Problem #3, Skin Integrity, initiated on 10/02/14; and Problem #4, Safety (Fall Risk), initiated on 10/02/14.

Review of the Master Treatment Plan revealed Problem #4, Safety (Fall Risk) was not implemented until 10/02/14.

In an interview on 11/06/14 at 10:11 a.m., S3ADON verified Patient #3 was not placed on "Fall Precautions" until 10/02/14. S3ADON confirmed Patient #3 was assessed as a "Moderate" risk for falls on 09/23/14 (admit date), and fall precautions should have been implemented for Patient #3 on 09/23/14.

Patient #5
Review of the medical record for Patient #5 revealed he was an 85 year old male admitted to the hospital on 9/18/14 with an admitting diagnosis of Delusional Disorder. His other diagnoses included Hypertension and exacerbation of Psychosis.

Review of the hospital document for Patient #5 titled Nursing Assessment revealed it had been completed on 9/18/14 at 12:30 p.m. Further review revealed Patient #5 had obtained a score of Moderate Risk (6-10). Interventions to be initiated with moderate fall risk were as follows: 1.Educated pt. (patient) on safe ambulation including asking for assistance when needed; 2. MHT (Mental Health Technician) notified to assist pt .getting in/out of wheelchair, bed, to and from bathroom; 3. MHT notified to offer bathroom q (every) 2 hours; 4. Encouraged proper use of assistive devices.

Review of Patient #5's Observational Check sheets revealed the patient's observational level was listed as monitoring every 15 minutes. Further review revealed the documented reason for the level of observation was fall precautions and behaviors.

Review of the document titled Interdisciplinary Patient Plan of Care for Patient #5, initiated 9/18/14, revealed fall risk had not been included as an identified problem in the patient's plan of care.

In an interview on 11/6/14 at 10:31 a.m., with S3ADON, he confirmed patients assessed as at risk for falls, on admit, should have been care planned for fall risk.

In an interview on 11/6/14 at 2:08 p.m., with S2DON, she said fall risk, identified upon admit, should have been addressed in the patient's care plans.


2) Failing to initiate fall risk as an identified problem on the patient's Interdisciplinary Plan of Care, after the patient had fallen, for 3 (#2, #4, #5) of 5 (#1-#5) patients sampled.

Patient #2
Review of the medical record for Patient #2 revealed she was a 26 year old female admitted to the hospital on 10/27/14 with an admitting diagnosis of Major Depressive Disorder, Recurrent and Severe. Her other diagnoses included Arthritis and Valvular Heart Disease.

Review of the hospital document for Patient #2, titled Nursing Assessment, revealed it had been completed on 10/27/14. Further review revealed Patient #2 had obtained a score indicative of low fall risk (0-5). No Interventions needed.

Review of Patient #2's Observational Check sheets, dated 10/27/14, revealed the patient's observational level was listed as monitoring every 15 minutes. Further review revealed the documented reason for the level of observation was fall precautions and acting out behaviors.

Review of Patient #2's Nurses Daily Assessment notes, dated 10/27/14 at 8:30 p.m. revealed the following, in part: "patient had begun vomiting in the hall before making it to the bathroom, grabbed wall railing, and then fell on floor onto her buttocks."

Review of the document titled Interdisciplinary Patient Plan of Care for Patient #2 revealed fall risk had not been included as an identified problem in the patient's plan of care after she had fallen on 10/27/14.

Review of the Patient Precautions List for 11/5/14 revealed Patient #2 was on fall precautions.

On 11/5/14 at 10:00 a.m., an observation was made of Patient #2 in the commons area. She was being monitored by a MHT for fall and behavioral precautions. She was frail looking and her hands were noted to have tremors. Patient #2 walked slowly and her balance was slightly unsteady.

Patient #4
Review of the medical record for Patient #4 revealed she was a 71 year old female admitted to the hospital on 9/13/14 with an admitting diagnosis of Psychosis. Her other diagnoses included CAD (Coronary Artery Disease), Hypertension, Hypothyroidism, DJD (Degenerative Joint Disease) and Schizophrenia.

Review of the hospital document for Patient #4, titled Nursing Assessment, revealed it had been completed on 9/13/14 at 1:40 a.m. Further review revealed Patient #4 had obtained a score indicative of low fall risk (0-5). No Interventions needed.

Review of Patient #4's medical record revealed no re-assessment of the patient's level of fall risk (except initially, on admit) to evaluate whether her level of risk had increased after she had fallen on 9/23/14 at 4:00 a.m. (sent to an area emergency room for evaluation and treatment); 9/24/14 at 1:30 a.m. (minor injuries sustained); and 9/24/14 at 6:20 a.m. (minor injuries sustained).

Review of Patient #4's Observational Check sheets, dated 9/20/14-10/1/14, revealed the patient's observational level was listed as monitoring every 15 minutes. Further review revealed the documented reason for the level of observation was fall precautions and acting out behaviors.

Review of Patient #4's Weekly Treatment Plan Updates with Physician Certification revealed the following entries:
9/18/14: Changes in Treatment Plan as directed by Multidisciplinary Team Conference
(Problems as identified on Master Treatment Plan):
1. Psychosis
2. Hypertension
New goals: blank; New interventions: blank
9/25/14: Changes in Treatment Plan as directed by Multidisciplinary Team Conference
(Problems as identified on Master Treatment Plan):
1. Psychosis
2. Hypertension
New goals: blank; New interventions: blank
Further review revealed Patient fall risk was not incorporated into the patient's plan of care during this treatment plan update meeting.

Patient #5
Review of the medical record for Patient #5 revealed he was an 85 year old male admitted to the hospital on 9/18/14 with an admitting diagnosis of Delusional Disorder. His other diagnoses included Hypertension and Exacerbation of Psychosis.

Review of the hospital's Patient/Visitor Hospital Occurrence Reports revealed Patient #5 had fallen, with minor injuries, on 9/22/14 at 6:35 a.m.

Review of Patient #5's medical record revealed no re-assessment of the patient's level of fall risk (except initially, on admit) to evaluate whether his level of risk had increased after he had fallen on 9/22/14 at 6:35 a.m.

Review of the document titled Interdisciplinary Patient Plan of Care for Patient #5, initiated 9/18/14, revealed fall risk had not been included as an identified problem in the patient's plan of care after he had fallen on 9/22/14 at 6:35 a.m.

In an interview on 11/6/14 at 8:24 a.m. with S8RN, she said as far as she knows, fall risk assessments (which determine levels of fall risk) were not performed after each fall to determine if the patient had progressed to the next level of fall risk/level of interventions. S8RN confirmed different levels of fall risk required initiation of new interventions. S8RN also confirmed care plans should have been updated after each patient fall.

In an interview on 11/6/14 at 10:31 a.m., with S3ADON, he confirmed patient care plans should have been updated after each fall. S3ADON said the fall risk assessment (which determined level of fall risk) should have been performed after each fall to determine whether the patient's risk had increased to the next level.

In an interview on 11/6/14 at 2:08 p.m., with S2DON, she confirmed patient care plans should have been updated after each fall. She also agreed that level of fall risk assessment, determining whether patient had advanced to a higher level of fall risk requiring a change in interventions, should have been performed after each patient fall.