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Based on medical record (MR) review, document review, and interview, in one (1) of three (3) MRs, the hospital failed to ensure nursing services were delivered as per facility policy.

This failure potentially placed all patients at increased risk of serious injury or harm.

Findings:

The facility failed to:

-Ensure nursing staff observed a patient identified as a fall risk and placed on 1:1 (constant) observation, as per facility policy.

(See Tag A-0398)

Based on medical record (MR) review, document review, and interview, nursing staff failed to observe a patient identified as a fall risk and placed on 1:1 (constant) observation, as per facility policy.

This failure potentially placed all patients at increased risk of serious injury or harm.

Findings:

Review of Patient #1's MR identified the following: Patient #1 was admitted to the Inpatient Rehabilitation Overflow Unit (3 West) on 7/25/2023 at 8:38PM. Patient #1 was assessed by the registered nurse (RN) as a high risk for falls at 9:30PM, and the Attending Physician ordered 1:1 continuous observation at 9:44PM. On 7/28/2023 at 11:37AM, Patient #1 was transferred to the Inpatient Rehabilitation Unit on 4 East. On 7/28/2023 at 3:00PM, Patient #1 fell. The patient sustained a laceration over the right eye, a hematoma (a bruise or collection of blood outside of a blood vessel), a C1 Jefferson fracture (a bone fracture of the vertebra C1), intraventricular hemorrhage (bleeding in the brain chambers), and a punctate acute infarct in the right splenium of corpus callosum (type of infarct commonly seen in patients with intraventricular hemorrhage).

An Incident Report dated 7/28/2023 at 3:00PM stated that Patient #1 was on 1:1 observation in a wheelchair next to the bed, with the wheelchair locked and seatbelt fastened. The certified nursing assistant (CNA) assigned to perform the 1:1 continuous observation stood in the doorway with their back turned towards Patient #1. The patient removed the seatbelt, stood up, and fell forward onto the floor. Patient #1 sustained a laceration over the right eye, a hematoma, and a C1 Jefferson fracture.

An Investigation Note dated 7/31/2023 at 1:40PM, identified that a per diem CNA was floated from another unit to Patient #1's unit, and was assigned to perform Patient #1's continuous 1:1 observation. The CNA stood in the doorway for approximately one (1) to two (2) minutes to look for their relief while Patient #1 sat in the wheelchair. When the CNA turned around, Patient #1 stood up, but the CNA could not reach the patient in time to mitigate the fall. The CNA acknowledged awareness of the Patient Observation policy, but admitted they were not in close proximity to Patient #1, nor that they kept Patient #1 in continuous sight at all times, as per facility policy.

The facility policy and procedure (P&P) titled, "Patient Observation: 1:1/ 2:1," last reviewed on 11/2/2021 stated the following: " ...The observing staff member must be in close proximity to the patient at all times. The patient is kept continuously in sight at all times ..."

Per interview of Staff I (Director of Risk Management) on 9/6/2023 at 2:33PM, Staff I confirmed these findings.

During interview of Staff A (Director of Nursing for Inpatient Rehabilitation) on 9/5/2023 at 1:34PM, Staff A stated that after Patient #1's fall occurred, the Patient Observation Policy was reinforced with the 4 East nursing staff during the 4 East Safety Operations Huddle.

Upon request, the facility could not furnish documented evidence of the huddle re-education/policy reinforcement conducted. The facility could not furnish documented evidence of the re-education content that was delivered and which personnel were captured. The facility could not furnish documented evidence that all applicable nursing personnel were re-educated and subsequently monitored.

These findings were discussed with Staff I and Staff A on 9/7/2023 at approximately 3:00PM during the Exit Conference.