HospitalInspections.org

Based on document review and interview the facility failed to ensure that patients received care in a safe setting in relation to 4 of 4 patients who fell and required transfer to a local acute care hospital for treatment and/or admission, patients #1, #2, #3 and #8.

Findings Include:
1. Review of the policy "Psychiatric Patients Rights", policy number I-A.16, issued/approved 5/15, indicated: "...You have the right to: 1. Appropriate mental health services and/or development training in accordance with standards of professional practice, appropriate to your needs and designed to afford you a reasonable opportunity to improve your condition...10. Humane care and protection from harm...".

2. Review of incident reports and medical records indicated:
A. Th discharge summary for Pt. #1 read: "On 06/10/16, at 10:40 a.m. (sic), the patient experienced a fall and was sent to the Emergency Department...for evaluation of left hip pain and was admitted...:. The "Wound Report" completed by nursing on 6/10/16 indicated the bruised area of the left hip/thigh measured 19 cm x 6 cm and the patient's range of motion was decreased. There was no nursing documentation in the medical record that a fall had occurred.

B. Patient #2 had documentation in :
a. Nursing notes on 6/4/16 at 4:50 PM that the patient "...urinated on self and bathroom floor, then attempted to transfer self from w/c (wheelchair) to bed w/o (without) assistance, losing balance and falling to knees. [no] injuries noted, assist X3 to get patient back in w/c."
b. Nursing notes on 6/5/16 at 6:00 AM that "Patient had fall in bathroom. Assessment completed. VS (vital signs) T (temperature)-97.1, B/P (blood pressure) 93/69, P (pulse) -85, R (respirations)-18."
c. The discharge summary on 6/10/16 that: "...Per nursing staff, [pt] fell overnight in the bathroom. No one saw. It was an unwitnessed fall...:." resulting in transfer and admission to a local acute care hospital.

C. Per medical record documenttion and incident reports, Patient #3 was being pushed in a w/c by a CNA (certified nursing assistant) on 5/31/16 and 6/1/16 when the patient "...reached forward out of wheelchair on the floor...". After the 5/31/16 fall, skin tears and bruising to the bridge of the nose was documented. The 6/1/16 fall required transfer and admission to a local acute care hospital.

D. Patient #8 had an order written on 6/14/16 to send the patient to ER (emergency room). There was also a note in the front of the chart that the long term care facility who referred the patient had been notified of a patient fall on 6/14/16. Pt. #8 had an incident report for a fall on 6/14/16 at 3:26 AM. The "Narrative" indicated: Pt was laying on left side by the foot of the bed on the floor when CNA walked in on pt. room. The patient's nose was deviated to the L side and a minor laceration 2 cm x 2 cm was noted over the patient's eyebrow. The pt. was sent out for CT (computed tomography) of face, head and neck and the outcome was a fracture of nasal bone.

3. At 1:50 PM on 6/27/16 and 3:45 PM on 6/28/16, interview with the CEO, staff member #50, and #53, the corporate compliance officer, confirmed that:
A. Even though the monthly fall report appeared that the number of falls had decreased, there were still serious injuries occurring for patients due to falls.
B. Falls were occurring due to the lack of implementation of the fall policy related to: accurate fall scores and documentation, initiating bed/chair alarms, 1:1 staffing when needed, and other interventions that could be utilized.
C. It is unclear how many falls Patient #2 sustained at the facility as documentation is not clear if there was one at 4:50 PM on 6/4/16, another the morning of 6/5/16 (or if that nurse was reporting the patient's fall of the previous day), and if there was another fall the night of 6/9/16 or the AM of 6/10/16, as noted in the discharge summary.

Based on document review and interview, it was determined that the hospital failed to protect and promote the rights for each patient. The hospital failed to ensure the implementation of facility policy regarding general safety and fall prevention (Refer to A 0395). The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the nursing services be supervised by a registered nurse.

Based on document review, observation and interview the nursing staff failed to supervise and evaluate the nursing care of patients by failing to implement the facility fall policy regarding the lack of scoring patients for risk of falls and failure to implement fall precautions for 9 of 10 patients, patients #1, #2, #3, #4, #5, #7, #8, #9 and #10; and in failing to initiate incident reports after patient falls for 3 of 3 patients noted by nursing charting to have fallen, patients #1, #2 and #3.

Findings Include:
1. The policy "Fall Risk Identification and Precaution", policy number II-A.9, revised 2/16, indicated: "1. All patients presenting for admission will be assessed and identified for fall risk during the Nursing Assessment. 2. SCUBA will be followed: S Socks (non-skid)...C Clutter free...U Unnecessary/unsafe medications or equipment...B Bed in safest position...A Alerting systems initiated...3. Fall Precautions will be documented on the patients Q15 minute observation form...".

2. Per the Nursing Admission Database form, on page 6, it was indicated that a Medium Risk for falls = score of 4 to 5 and that the following will be implemented: "Line of Sight, Bed/Chair Alarms, Stand By Assist When Ambulatory, Exercise class (sic)"; and for those at a High Risk for falls = score of 6-7: "Assess for 1:1, PT (physical therapy) Consult, room close to Nurses Station, Toileting Schedule".

3. Review of medical records indicated:
A. Pt. #1 was a 78 year old admitted at 10:00 PM on 6/3/16 and discharged on 6/9/16. The admission Fall Risk Factor Assessment area of the Admission Database form was not completed nor totaled for a risk score. Other documentation included:
a. On 6/4/16 and 6/8/16, the Daily Nursing Record form for NAs (nurse aides) lacked a check that the "Fall Band" was on the patient on either the "AM" (day shift) or "PM" (eve/night shift) time periods. The 6/5/16, 6/6/16 and 6/9/16 NA Daily Nursing Record form lacked an "AM" check of the "Fall Band". The 6/7/16 NA Daily Nursing Record for lacked a "PM" check of the "Fall Band" being present on the patient.
b. On 6/4/16, the day shift Daily Nursing Record form (for nursing staff) had the patient scored at 4 (out of 7) for a "moderate" risk for falls (moderate = score of 4 or 5), and noted the patient was a "fall" risk with no documentation of what, if any, precautions were implemented. The night shift Daily Nursing Record form for 6/5/16 had no fall risk assessment completed, had the patient checked as a fall risk but lacked any documentation of fall precautions that might have been implemented.
c. The patient had a fall at 10:40 AM on 6/10/16 that caused a decrease in range of motion and an increase in pain with ultimate transfer to a local acute care hospital for admission.

B. Patient #2 was a 69 year old admitted on 5/31/16 and discharged on 6/13/16. The Nursing Admission Database form indicated the patient scored 4 (out of 7) for a moderate risk for falls. Other documentation included:
a. The Admission Fall Risk Assessment - Intervention Activation form was completed at 9:00 PM on 5/31/16 and indicated the patient needed stand by assist when ambulatory, the bed in lowest/locked position, a walker/wheelchair, and a toileting schedule.
b. The Daily Nursing Record form for NAs lacked checking that the AM and PM shifts noted a fall band on the patient on 6/2/16, 6/4/16, 6/5/16, 6/7/16 and 6/8/16.
c. On the Patient Observation and Monitoring form, "Fall" Precautions were not marked on 6/2/16, 6/6/16 and 6/7/16.
d. The Daily Nursing Record forms for nurses lacked documentation of the fall precautions that were implemented on days for 6/2/16 and 6/9/16 and with only "line of sight" listed as a precaution on 6/4/16 and 6/10/16.

C. Patient #3 was a 77 year old admitted on 5/29/16 at 12:14 PM and discharged on 6/1/16. The Nursing Admission Database form indicated the patient was a 4 (out of 7) fall risk. Further documentation in the record included:
a. The Admission Fall Risk Assessment - Intervention Activation form dated 5/29/16 at 1:00 PM listed the fall score as 12, with the scoring tool only going as high as 7. The only precautions checked were bed in lowest/locked position, walker/wheelchair, and toileting schedule.
b. The NA Daily Nursing Record form lacked a check mark to indicate the patient's Fall Band was on during the 5/29/16 and 5/30/16 night shifts and the 5/31/16 and 6/1/16 day shifts. A Bed Alarm and Personal Alarm were not checked as being in place on 5/29/16 and 6/1/16 and were both checked as not applicable on 5/30/16 and 5/31/16.
c. The Patient Observation Monitoring Rounds document used by NAs lacked the checking of "Fall" precautions on their worksheets for 5/29/16 and 5/30/16.
d. Nursing notes on the Daily Nursing Record form for 5/29/16 and 5/31/16 (day and night shifts) indicated a score of 4 in the fall assessment area with "Fall" precautions noted, but no notation of what precautions were implemented. The 5/30/16 day shift nurse failed to total a fall score, listed the patient with fall precautions but did not indicate which precautions were initiated. The 5/30/16 night shift scored the patient at 4, listed fall precautions and failed to document the precautions implemented.

D. Pt. #4 was an 89 year old admitted on 5/17/16 and discharged on 6/3/16. The Nursing Admission Database form indicated the patient scored a 5 (out of 7) for fall risk. Further documentation indicated:
a. The Patient Observation Monitoring Rounds form (used by NAs) lacked indication that the patient was on fall precautions on 5/21/16 and 5/30/16.
b. The Fall Band area of the Daily Nursing Record (for NAs) lacked indication that a fall band was on for: PM on 5/17/16, 5/26/16 and 6/2/16, AM on 5/19/16, 5/22/16, 5/23/16, 5/24/16, 5/27/16, 5/28/16, 5/29/16 and 6/1/16, and for both the AM and PM on 5/21/16, 5/25/16, 5/30/16 and 5/31/16.
c. The Daily Nursing Record form for nurses noted the patient was a fall risk of 4, with precautions implemented not noted on the day shift for 5/17/16, 5/19/16, 5/21/16, 5/24/16 and 6/2/16; for the night shift on 5/20/16, 5/21/16, 5/22/16, 5/23/16; and the night shift of 5/25/16 and the day shift of 5/26/16 lacked a fall risk score documentation being completed. Nursing listed the pt as a fall risk on those days, but no specific precautions were noted as having been implemented.

E. Patient #5 was a 90 year old current patient who was admitted on 6/16/16. The Nursing Admission Database form dated 6/16/16 at 11:00 PM scored the patient at 4 on the updated form. Medium risk for scores of 4-5 indicate precautions to implement = "Line of Sight, Bed/Chair Alarms, Stand By Assist When Ambulatory, Exercise class.". Other notations in the record included:
a. The Admission Fall Risk Assessment - Intervention Activation form indicated no line of sight, bed or chair alarm was implemented/activated for the patient and no fall score was noted on the form in the appropriate place.
b. The Patient Observation Monitoring Rounds form lacked noting that the patient was on Fall Precautions on 6/18/16 and 6/22/16.
c. The Daily Nursing Record form (for NAs) lacked noting a Fall Band on the patient for the AM and PM shifts on 6/18/16, 6/22/16, 6/23/16 and 6/24/16; for the PM shift on 6/20/16 and 6/21/16; and for the AM shift on 6/26/16 and 6/27/16.
d. The Daily Nursing Record form for nurses: lacked a fall score on 6/16/16, 6/20/16 and 6/26/16 (night shift); listed the patient as on fall precautions, but lacked indication of which precautions were initiated; listed the patient as score risk of 4 on 6/18/16 (day and night shifts), day shift on 6/19/16, 6/25/16 and 6/27/16, and night shift 6/19/16, 6/21/16, 6/22/16, 6/25/16 and 6/27/16, noted the patient was a fall precaution, but lacked indication of which precautions were initiated.
e. The patient was observed on 6/28/16 to have no yellow dot on their wrist band that would indicate they were a fall risk.

F. Pt. #7 was an 80 year old current patient admitted on 6/21/16. The Nursing Admission Database form indicated the patient was a score of 3 for fall risk (low risk). Other medical record documentation indicated:
a. The Patient Observation Monitoring Rounds form for 6/22/16, 6/23/16, 6/24/16, 6/25/16, 6/26/16, and 6/27/16 indicated on page one that the patient was on fall precautions but lacked a check in the box for either the AM or PM, or both shifts, that the Fall Band was on the patient.
b. On the Daily Nursing Record form for nurses, the 6/22/16 fall score (night shift) was 4 with fall precautions checked, but no specific precautions noted, the day and night shifts for 6/23/16, 6/25/16 and 6/27/16 and nights on 6/24/16 and 6/26/16 scored the patient at a level of 3, checked that the patient was on fall precautions, but failed to list the precautions initiated.
c. The patient had no yellow dot on their wrist band when observed on 6/28/16.

G. Pt. #8 was a current 61 year old patient admitted on 6/13/16. The Nursing Admission Database form indicated the patient scored a 5 (out of 7) for fall risk (medium risk). Medium risk for scores of 4-5 indicate precautions to implement = "Line of Sight, Bed/Chair Alarms, Stand By Assist When Ambulatory, Exercise class." The Admission Fall Risk Assessment - Intervention Activation form done at 4:07 PM on 6/13/16 lacked the admission fall risk score and indicated no line of sight or bed or chair alarm was to be utilized for the patient. Further information in the medical record included:
a. The Daily Nursing Record form for nurses (day shift) lacked a fall score total on page 4 on 6/24/16 and the night shifts of 6/25/16 and 6/27/16 lacked a fall score total on the forms.
b. On the Patient Monitoring Rounds form fall precautions were not circled as a precaution for this patient. The Fall Band was not checked as initiated for the day or night shift on 6/24/16, 6/25/16, 6/26/16 and 6/27/16 and no device alarms were checked as being implemented. Device alarms were checked as not applicable on 6/20/16, 6/21/16, 6/22/16 and 6/23/16.
c. The patient had no yellow dot on their wrist band when observed on 6/28/16.

H. Pt. #9 was a 59 year old current patient admitted 6/14/16. The Nursing Admission Database form indicated the patient scored a 7 out of 7 for a High Risk for falls. High Risk = score 6-7: Assess for 1:1, PT (physical therapy) consult, room close to Nurses Station, Toileting Schedule. The Admission Fall Risk Assessment - Intervention Activation form dated 6/14/16 at 7:07 PM indicated the fall score was 7, but the 1:1 assessment, PT consult, Move patient's room closer, and bed and chair alarm were not marked (areas were blank). There was also no notation that a toileting schedule was implemented. Other documentation noted in the medical record indicated:
a. The Patient Observation Monitoring Rounds form (for NAs) lacked notation of fall precautions on 6/15/16, 6/18/16 and 6/27/16.
b. The Daily Nursing Record form for NAs lacked noting the Fall Band was on the patient on the day shift, the evening shift or both shifts on 6/15/16, 6/17/16, 6/19/16, 6/20/16, 6/21/16, 6/22/16, 6/23/16, 6/24/16, 6/25/16 and 6/27/16.
c. The Daily Nursing Record form for NAs had bed and personal alarms either not checked at all or checked as not applicable for the day shift, the evening shift or both shifts on 6/15/16, 6/17/16, 6/19/16, 6/20/16, 6/21/16, 6/22/16, 6/23/16, 6/24/16, 6/25/16 and 6/27/16.
d. The Daily Nursing Record form for nurses had a fall score of 4 on 6/14/16 and 6/22/16 for the night shift with fall precautions checked, but no listing of which precautions were utilized; a score of 4 on the day shift for 6/16/16 and 6/19/16 with fall precautions checked, but no listing of which precautions were utilized; no scoring for falls completed on the day shift of 6/16/16 and the night shifts on 6/20/16 and 6/26/16.

I. Pt. #10 was a current 75 year old patient who was admitted on 6/21/16. The Nursing Admission Database indicated the patient scored at a 4 for fall risk. Other documentation included:
a. There was no care planning for fall risk.
b. The Patient Observation Monitoring Rounds form for nurse aides lacked notation of fall precautions on 6/21/16 and 6/25/16.
c. Documentation of the Fall Band being on the patient was not documented for the night shift on 6/21/16, 6/26/16 and 6/27/16; on the day shift on 6/22/16 and 6/23/16; or for either shift on 6/25/16.
d. The Daily Nursing Record form for nurses on 6/27/16 (night shift) lacked a fall score completion, listed the patient as being on fall precautions, but failed to list the precautions initiated.
e. The patient had no yellow dot on their wrist band to indicate fall risk.

4. At 10:05 AM on 6/28/16, interview with the quality/risk director, staff member #51, confirmed that:
A. The fall band is not addressed in the fall policy as part of interventions to be implemented but is an expectation for those at risk for falls.
B. Documentation of a fall band being in place is to be noted on the "Daily Nursing Record" form (Intake and Output form) on page 1 of 5 that nurse aides complete on each shift.
C. With this staff member's monthly review of open medical records, the same lack of documentation and deficiency related to implementation of the fall policy had been noted as that which was found deficient in the records listed in 8. above.
D. The Nursing Admission Database form listed in 8 above is the most current and to be implemented by nursing, but some are still utilizing the old form that is not as specific about which interventions to implement with medium and high risk scores.

5. At 10:30 AM on 6/28/16, interview with the corporate compliance officer, staff member #53, confirmed that a fall band is no longer used, but a yellow fall dot is placed on the patients identification/name band to alert staff that the patient is a fall risk.

6. At 1:50 PM on 6/27/16 and 3:45 PM on 6/28/16, interview with the CEO, staff member #50, and #53, the corporate compliance officer, confirmed that the facility had been aware that the fall policy, related to the lack of documentation, and that nursing staff had been instructed to complete forms.

7. The policy "Fall Risk Identification and Precaution", policy number II-A.9, revised 2/16, indicated: "Post-Fall Management The interdisciplinary team will:...3. Complete report and detailed progress note...".

8. Review of facility incident reports for May and June 2016 indicated:
A. Pt. #2 had no incident report forms completed for two falls and two incidents that were documented in nursing notes:
a. At 4:50 PM on 6/4/16, nursing noted: "...Patient urinated on self and bathroom floor, then attempted to transfer self from w/c (wheelchair) to bed w/o (without) assistance, losing balance and falling to knees...".
b. On 6/5/16 at 6:00 AM, the night nurse noted: "Patient had fall in bathroom. Assessment completed...".
c. On 6/9/16 (no time noted), the day nurse wrote: "Patient alert and oriented to self...sitting in the day room [pt] crawled out of [their] chair to [their] knees was able to get up with minimal assist...".
d. On 6/9/16 at 2:30 PM, nursing charted: "Patient crawled to [their] knees again from wheelchair staff of 4 assisted back to wheelchair."

B. Patient #3 had no incident report created, but had nursing notes on 5/31/16 at 12:40 PM that indicated: "Patient was being pushed in wheelchair by cna (sic) (certified nursing assistant), patient reached forward out of wheelchair on the floor before cna could hold onto [pt],...".

C. There was no incident report related to a fall episode for Patient #1 that occurred on 6/9/16 or 6/10/16. Per the discharge summary: "On 06/10/16, at 10:40 a.m.(sic), the patient experienced a fall and was sent to the Emergency Department...for evaluation of left hip pain and was admitted...". There was also no documentation in the medical record, by nursing staff, to indicate the patient had a fall during their hospitalization at the facility.


9. Review of the policy "Incident Reports", policy number III-B.11, last issued/approved 5/15, indicated: "...An Incident is defined as: any event which is not consistent with the routine operation of Neuropsychiatric Hospital of Indianapolis and that adversely affects or threatens to affect the well-being of the Patients...regardless of whether an actual injury is involved or not."

10. At 1:30 PM on 6/27/6, interview with staff member #52, the assistant director of nursing, confirmed that patient #1 had a fall on the evening/night shift of 6/9/16 that nursing failed to document in the medical record, or on an incident report form.

11. At 3:15 PM on 6/27/16, interview with staff member #52, the assistant director of nursing, confirmed that patient #2 had:
A. Falls on 6/4/16 and 6/5/16 documented in the patient's medical record lacked completion of incident reports regarding these events.
B. No incident reports completed for the two 6/9/16 episodes in which the patient crawled out of their w/c and onto their knees on the floor,

12. At 1:10 PM on 6/28/16, interview with staff member #53, the corporate compliance officer, confirmed that Patient #3 had a fall from their w/c on 5/31/16 at 12:40 PM, but no incident report was completed.