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Based on record review, interview and policy review, it was determined that the Medical Director failed to assure that the hospital provided clear policies and procedures for prevention of patient falls. One of 2 sample patients (F1) who sustained injuries from falls since the recertification survey fell when she/he was toileting alone in his/her bathroom, despite being on "Fall Precautions." However, the hospital failed to have policies and procedures that defined the term "Fall Precautions" or that specified what staff interventions would be needed for the various levels of fall risk. Staff gave different interpretations of the terms "Fall Precautions"; "Fall Prevention measures"; "set-up assist"; and "stand-by assist." The hospital also failed to train the staff in Fall Prevention measures or to assign responsibilities to the clinical disciplines for the ordering and/or implementation of these measures. Failure to define Fall Precaution/Prevention measures and train staff in their implementation leads to confusion on the part of staff and places patients at risk of inadequate safety measures being employed in their care.

Findings include:

A. Record Review

Patient F1 was an elderly patient admitted 2/16/11 to the Older Adult Unit (OAU) for Major Depression and Vascular Dementia. According to the Psychiatric Admission Assessment of 2/16/11, s/he had a previous left hip fracture. At the time of admission, she was placed on "Fall Precautions." The patient was having her medications adjusted, received six courses of ECT, and was progressing in treatment. On the evening of 3/20/11 the patient fell while alone in the bathroom, and she fractured her right hip. She was transferred to an acute care hospital for further medical care and was discharged from the Pine Rest facility.

B. Interviews

1. On 5/5/11 at 10a.m., the surveyor met with the hospital's Fall Team to review the 3/20/11 fall of patient F1. Staff attending the meeting included the Chief Nurse Executive (CNE), the RN Manager and Lead RN of the OAU, the RN Manager of the Child and Adolescent Unit, the Director of Clinical Practice, the hospital Risk Manager, and the Quality Coordinator. The interviewees were asked to explain the process of fall risk evaluation, fall precautions and the management of patient falls. There was considerable confusion on the part of the Fall Team regarding hospital policy and procedures. The OAU Lead RN stated that a patient would be placed on "Fall Precautions" following a nursing or physician assessment and with a physician's order. If a patient on Fall Precautions triggered certain criteria in the Electronic Medical Record (EMR) system, a box would appear asking if the RN wanted to order "Fall Prevention" measures. Members of the Fall Team explained that Fall Prevention measures were more stringent than Fall Precautions and are considered "enhanced" Fall Precautions. When the surveyor asked what criteria would trigger the Fall Prevention measures, none of the Fall Team members could answer the question. All interviewees agreed that it was an automatic function of the Electronic Medical Record. When asked who orders Fall Prevention measures, there was disagreement among members of the Fall Team as to whether a nurse or a physician should do the orders. The lead RN from the OAU stated that she routinely orders Fall Prevention measures. The CNE and the RN Manager of the OAU stated that Fall Prevention measures should be physician ordered.

The surveyor asked how an RN could order the Fall Prevention measures if they were more restrictive than the Fall Precautions, which by the facility's policy PC-108, Observation and Special Precautions, require a physician's order. Members of the Fall Team acknowledged that this was not logical. When the surveyor asked whether RNs had privileges to order Fall Prevention measures, the CNE said they do not. When the surveyor asked whether Fall Precautions or Fall Prevention measures were described in a policy or procedure, the Risk Manager stated they were not. The Risk Manager added that the information was in "bits and pieces" in multiple places, but not in one complete document. Following further discussion, it was determined that Fall Prevention measures, despite being considered "enhanced" Fall Precautions by clinical staff, are not described in the hospital policy PC-108, Observation and Special Precautions. Members of the Fall Team came to the consensus that the Fall Prevention measures which they routinely employ are generated by the EMR system, and are not created by hospital staff. They are triggered by criteria in the EMR which the staff does not understand. They are considered more restrictive than Fall Precautions, but are not ordered or employed consistently by the clinical staff. The CNE stated that there was not any hospital policy, procedure or training document which contains the definitions and procedures for Fall Precautions or Fall Prevention measures. The CNE acknowledged that there was significant staff confusion regarding the responsibility for ordering Fall Prevention Measures.

In further discussion with the Fall Team regarding the 3/20/11 fall of patient F1, the RN Manager of the OAU stated that patient F1 had been on Fall Precautions and "setup-assist" protocol at the time of her 3/20/11 fall. The RN Manager acknowledged that there is no protocol called "setup-assist," and that this had been identified as a source of confusion in the review of the fall incident. The hospital recognizes the term "standby-assist." However the hospital does not define this term in a policy or procedure, and direct care staff interprets the term in various ways.

2. In an interview on 5-5-11 at 1:15p.m., the Medical Director was asked to describe the hospital's Fall Precautions and Fall Prevention measures, and who was responsible for ordering them. The Medical Director stated that RNs routinely call physicians for Fall Precaution orders, but that he does not know what happens after that. The Medical Director said he did not know what Fall Prevention measures were or who had the responsibility to order them. The Medical Director stated that hospital leaders have regarded the issue of patient falls as a nursing issue.

3. In an interview with Patient Care Provider 1 [PCP1] on the Older Adult Unit on 5-5-11 at 1:30p.m., PCP1 stated that there was no distinction between Fall Precautions and Fall Prevention measures. PCP1 stated she was not familiar with Fall Prevention measures. When PCP1 was asked to describe the level of assistance that patients on Fall Precautions required, she replied that they were on "standby-assist." PCP1 was asked whether the term "standby-assist," or what it instructs her to do, is available in writing. She stated that it was not. When asked to define what "standby-assist" means, PCP1 stated that it means you keep a close watch on everyone

4. In an interview on 5-5-11 at 1:35p.m., with the CNE, the Lead RN of the Older Adult Unit and the Unit RN Manager of the Older Adult Unit, the RN Manager acknowledged that Fall Prevention measures, although routinely used in the hospital, are not defined in policy or procedure, nor is the staff formally trained in how to implement these procedures. The RN manager stated that she recalled having protocols in the past which defined and described fall procedures and staff responsibilities, but these were discontinued when the EMR (Electronic Medical Record) was introduced. Lead RN stated that she had consulted other unit RNs and had confirmed that it is hospital practice for RNs to order and implement Fall Prevention measures, despite the fact that they are more restrictive than Fall Precautions which require a physician's order. The CNE acknowledged that RNs are not privileged to enter such orders into medical records, and that significant confusion exists about their ordering and usage.

C. Document Review

Hospital Policy PC-108, Patient Observations and Special Precautions, revised 6/3/09, states on page 3: "Fall Precautions: Applies to the patient who by history and/or assessment using the Morse Fall rating scale on the electronic medical record indicates the patient is at risk for falling." The policy has no further description of Fall Precautions. The policy does not define Fall Prevention measures or describe the staff responsibilities for ordering and implementing these measures. The policy also does not define or describe the terms "setup-assist" or "standby-assist."

Based on interviews and record review, the Director of Nursing (DON) failed to assure that there were adequate policies and procedures in place for prevention of patient falls, and that nursing staff completed training in the proper implementation of these policies and procedures. The hospital did not have a policy that clearly described the various levels of fall risk or that specified what nursing interventions were required for patients at different risk levels. Nursing staff had different interpretations of the terms "Fall Precautions"; "Fall Prevention measures"; "set-up assist"; and "stand-by assist." They did not receive any specific training for Fall Prevention measures, and there was considerable confusion among the nurses about what was required. In addition, nurses were allowed to write orders for Fall Prevention measures which were outside of the scope of nursing practice. Failure to provide clear policies and procedures for prevention of patient falls, and delineate the nursing role in Fall Prevention measures places patients at risk of not receiving adequate safety measures. Failure to assure that nurses do not assume responsibilities outside of the scope of nursing practice can also result in harm to patients.

Findings include:

A. Interviews

1. On 5/5/11 at 10a.m., the surveyor met with the hospital's Fall Team to review a fall that that occurred on 3/20/11. The patient (F1) was an elderly female patient who had fallen and sustained an injury when toileting by herself, despite being on physician-ordered "Fall Precautions." Staff attending the discussion included the Chief Nurse Executive (CNE), the RN Manager and Lead RN of the OAU, the RN Manager of the Child and Adolescent Unit, the Director of Clinical Practice, the hospital Risk Manager, and the Quality Coordinator. The interviewees were asked to explain the process of fall risk evaluation, fall precautions and the management of patient falls. There was considerable confusion on the part of the Fall Team regarding hospital policy and procedures. The OAU Lead RN stated that a patient would be placed on "Fall Precautions" following a nursing or physician assessment and with a physician's order. If a patient on Fall Precautions triggered certain criteria in the Electronic Medical Record (EMR) system, a box would appear asking if the RN wanted to order "Fall Prevention" measures. Members of the Fall Team explained that Fall Prevention measures were more stringent than Fall Precautions and are considered "enhanced" Fall Precautions. When the surveyor asked what criteria would trigger the Fall Prevention measures, none of the Fall Team members, including the CNE, could answer the question. All interviewees agreed that it was an automatic function of the Electronic Medical Record. When asked who orders Fall Prevention measures, there was disagreement among members of the Fall Team as to whether a nurse or a physician should do the orders. The lead RN from the OAU stated that she routinely orders Fall Prevention measures. The CNE and the RN Manager of the OAU stated that Fall Prevention measures should be physician ordered.

The surveyor asked how an RN could order the Fall Prevention measures if they were more restrictive than the Fall Precautions, which by the facility's policy PC-108, Observation and Special Precautions, require a physician's order. Members of the Fall Team acknowledged that this was not logical. When the surveyor asked whether RNs had privileges to order Fall Prevention measures, the CNE said they do not. When the surveyor asked whether Fall Precautions or Fall Prevention measures were described in a policy or procedure, the Risk Manager stated they were not. The Risk Manager added that the information was in "bits and pieces" in multiple places, but not in one complete document. Following further discussion, it was determined that Fall Prevention measures, despite being considered "enhanced" Fall Precautions by clinical staff, are not described in the hospital policy PC-108, Observation and Special Precautions. Members of the Fall Team came to the consensus that the Fall Prevention measures which they routinely employ are generated by the EMR system, and are not created by hospital staff. They are triggered by criteria in the EMR which the staff does not understand. They are considered more restrictive than Fall Precautions, but are not ordered or employed consistently by the clinical staff. The CNE stated that there was not any hospital policy, procedure or training document which contains the definitions and procedures for Fall Precautions or Fall Prevention measures. The CNE acknowledged that there was significant staff confusion regarding the responsibility for ordering Fall Prevention Measures.

In further discussion with the Fall Team regarding the 3/20/11 fall of patient F1, the RN Manager of the OAU stated that patient F1 had been on Fall Precautions and "setup-assist" protocol at the time of her 3/20/11 fall. The RN Manager acknowledged that there is no protocol called "setup-assist," and that this had been identified as a source of confusion in the review of the fall incident. The hospital recognizes the term "standby-assist." However the hospital does not define this term in a policy or procedure, and direct care staff interprets the term in various ways.

2. In an interview on the Older Adult Unit on 5-5-11 at 1:30p.m., Patient Care Provider 1, [PCP1], stated that there was no distinction between Fall Precautions and Fall Prevention measures. PCP1 stated she was not familiar with Fall Prevention measures. When PCP1 was asked to describe the level of assistance that patients on Fall Precautions required, she replied that they were on "standby-assist." PCP1 was asked whether the term "standby-assist," or what it instructs her to do, is available in writing. She stated that it was not. When asked to define what "standby-assist" means, PCP1 stated that it means you keep a close watch on everyone.

3. In an interview on 5-5-11 at 1:35p.m., with the CNE, the Lead RN and Unit RN Manager of the OAU, the RN Manager acknowledged that Fall Prevention measures, although routinely used in the hospital, are not defined in policy or procedure, nor is the staff formally trained in how to implement these procedures. The RN manager stated that she recalled having protocols in the past which defined and described fall procedures and staff responsibilities, but these were discontinued when the EMR (Electronic Medical Record) was introduced. The Lead RN stated that she had consulted other unit RNs and had confirmed that it is hospital practice for RNs to order and implement Fall Prevention measures, despite the fact that they are more restrictive than Fall Precautions which require a physician's order. The CNE acknowledged that RNs are not privileged to enter such orders into medical records, and that significant confusion exists about their ordering and usage.

B. Document Review

Hospital Policy PC-108, Patient Observations and Special Precautions, revised 6/3/09, states on page 3: "Fall Precautions: Applies to the patient who by history and/or assessment using the Morse Fall rating scale on the electronic medical record indicates the patient is at risk for falling." The policy has no further description of Fall Precautions. The policy does not define Fall Prevention measures or describe the staff responsibilities for ordering and implementing these measures. The policy also does not define or describe the terms "setup-assist" or "standby-assist."