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Based on policy review and interview, the Critical Access Hospital (CAH) failed to ensure that hospital policies and procedures were reviewed at least biennially by a group of professional personnel required under paragraph (a)(2) of this section and reviewed as necessary by the CAH.

The Governing Body's failure to ensure the hospital is reviewing and/or updating policies and procedures at least biennially places any patient or employee at this hospital at risk for non-compliance related to failure to comply with new laws and regulations, which can result in inconsistent outdated practices resulting in poor patient outcomes and safety concerns.

Findings Include:

On 05/01/23 at 2:00 PM, the surveyors requested copies of the Hospital's behavioral health policies including but not limited to suicide risk assessment, suicide prevention, and monitoring of patients at risk for suicide/self harm.

On 05/01/23 at 2:00 PM, Staff A, CNO stated that the hospital did not have behavioral health policies to provide.


Review of the Hospital's Policy and Procedures provided showed the following policies were not reviewed and/or revised at least biennially:

"Admission Nursing Assessment," revised 11/18

"Administration of Medications," revised 7/20

"Verbal or Telephone Orders," revised 9/20

"Swingbed/Respite Patient Rights." revised 2/20


On 4/24/23 at 1:15 PM, Staff A, CNO stated that the hospitals policies are lacking and she is working on getting the policies up to date.

Based on policy review, record review, observation and interview the Critical Access Hospital (CAH) failed to ensure a nursing care plan was kept current for six of nine patients (Patients 2, 3, 4, 6, 7, and 8) as evidenced by the failure to update care plans as the patients' needs change.

The hospital's failure to properly implement and update care plans for six of nine patients (Patients 2, 3, 4, 6, 7, and 8) places any patient receiving services at this hospital at risk for not having their needs met.

Findings Include:

Review of a policy titled, "Swingbed Assessment and Care Plan Policies & Procedures" revised 12/2021, showed, " ...5. On ISB [Intermediate Swingbed] patients the Charge nurse of ISB Supervisor will address care plan problems as needed on paper care plan and quarterly. 6. The Charge nurse will review care plan daily and keep it updated ...9. The ISB Supervisor will notify disciplines of the need to do a new care plan for ISB Patients ..."


Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was admitted to Intermediate Swing Bed (ISB) on 09/15/21 for custodial care with a diagnosis of dementia and self-care deficit with history of falls. On 4/20/23, Patient 2 was discharged/transferred to another hospital for a psychosocial assessment/evaluation for progressing behavioral issues.

Review of Patient 2's Restorative Care Plan (undated), showed the following:

Problem: Potential for injury due to poor balance, falls, and a hazardous environment. Goal: To prevent falls and identify any possible environmental hazards. Interventions: Encourage patient to exercise with Restorative Aide regularly, or to perform other activities that promote balance, such as walking; Encourage patient to wear proper fitting footwear; Observe the patient's ability to ambulate and whether the patient uses assistive device. Outcome: Patient will remain free of falls, and any fall related injuries.

Problem: High risk for falls related to being unaware of safety needs, poor communication/comprehension, gait/balance problems, and incontinence. Goal: Prevent falls and promote patient safety. Interventions: Encourage patient to perform ADLs such as hair combing, dressing, using the bedside commode or toilet; Anticipate and meet needs; Always keep call light within reach of patient; Promptly answer any call lights. Outcome: Patient will remain free of falls and fall related injuries.

Problem: Potential for falls, out of bed, or out of chair. Goal: Promote patient safety and reduce the risk of fall related injuries. Interventions: Chair alarm in wheelchair or recliner to alert staff of patient rising unassisted ...monitoring tools in place for proper documentation; Bed alarms while patient is in bed to alert staff of patient rising unassisted ...monitoring tools in place for proper documentation; Bed in low position. Outcome: No falls or fall related injuries after implementing the above interventions.

Staff L, RN, reviewed Patient 2's Care Plan on 10/05/21 (16 days after Patient 2's fall on 09/19/21) and stated, "Reviewed and will continue with plan." Staff L, RN did not address Patient 2's fall in the care plan and no revisions were made to the plan of care to address goals not being met or putting any additional interventions in place to prevent falls.

An undated and unsigned note on the Patient 2's care plan showed the following, "The patient fell on 10/23/21 and again on 10/27/21, UA collected due to increased confusion on 10/27/21. The urine sent out for a C&S. Cipro (Ciprofloxacin - an antibiotic) started on 10/29/21 500mg PO Daily for 5 days. No injuries for either fall." Staff L, RN made no revisions to the fall interventions.

On 12/08/21, Staff L, RN stated, "Bed and chair alarms placed on the patient due to unstable walking and to remind her to seek assistance in transfers/ambulation. Reviewed and updated." (Chair and bed alarms were already included in the plan of care.) Staff L, RN made no further revisions to fall interventions. On 01/27/22, Staff L, RN wrote on the care plan, "Reviewed will continue with plan." On 02/03/22, Staff L, RN wrote on the care plan, "Reviewed and will continue with plan."

On 04/14/23 the Care Plan Meeting Notes/Updates showed, "No significant changes at this time ..." Nursing staff failed to address any of Patient 2's falls with revisions to fall risk interventions or goals to address Patient 2's numerous falls throughout her hospitalization.

Review of Patient 2's Care Plan dated 04/20/23, showed the following, " ...[Patient 2] will remain free from fall-related injuries throughout the next 60 days ...Staff will assist [Patient2] with a transfer or walking with one or two-staff assist walker and gait belt. Staff will watch [Patient2] for signs and symptoms of fatigue and offer to assist her with the wheelchair ...Staff will assist [Patient 2] with all elimination needs. [Patient 2] doesn't always ask to use the bathroom, staff will offer to taker her before and after meals and activities, and when she wakes up from sleeping ...Staff will assist with all ambulating. Staff will assist with all toileting needs ...Staff will do a fall assessment monthly and with a fall. [Patient 2] has a chair and bed alarm to help alert staff if she is trying to get up unassisted. [Patient 2] may use ½ side bed rail, if desired, for safety, &/or for repositioning & transfers while in bed ..."



Patient 3

Review of Patient 3's active medical record showed that Patient 3 was admitted to Intermediate Swing Bed (ISB) on 05/13/21 for custodial care with a diagnosis of cognitive impairment, dementia, and hypertension.

Review of the Plan of Care for Patient 3, dated 07/21 and updated 08/21, showed Patient 3 had a potential for injury related to falls, secondary to; age of 65 years or older; use of assistive device for mobility; diminished mental status; impaired balance; neuropathy; and an injury fall that occurred 12/13/22 and a non-injury fall that occurred 02/11/23. Interventions listed on the Plan of Care included the following: Encourage patient to exercise regularly or other activities that improve balance; Instruct patient to rise slowly from sitting or lying position; Clutter free environment; Clean floor spills immediately; Keep items within reach; Bed in lowest position; Call light within reach; non-skid footwear/slippers; Use of eyeglasses; Assessment of mental status changes; Assessment of medications that may contribute to falls including hypnotics, diuretics, nitrates, antihypertensives, antidepressants, and digitalis. Outcome stated that Patient 3 will remain free from fall related injuries throughout the next 60 days. It was noted on the Plan of care, "The patient does not want the side rails up." The care plan also noted that Patient 3 will forget to use her cane and needed to be reminded or have it retrieved for her.

Review of an update to the Plan of Care dated 02/01/23 showed that Patient 3 would be started on Fentanyl (a narcotic medication used for pain control with side effects that may include sedation, confusion, and dizziness which may increase fall risk) 12 mcg/hour patch for pain effective 02/03/23. On 02/15/23 the Fentanyl patch dosage was increased to 25 mcg/hour effective 02/18/23. On 03/05/23 the Fentanyl patch was again increased to 50 mcg/hour. The Plan of Care failed to show documented evidence of increased monitoring or implementation of additional fall interventions with the addition of an increased dosage of a medication that could contribute to falls. Although the Plan of Care acknowledged that Patient 3 had two falls (one of which resulted in injury), nursing staff failed to show evidence that the Plan of Care was revised to implement further fall interventions to prevent falls from re-occurring.


Patient 4

Review of Patient 4's active medical record showed that Patient 4 was admitted to Intermediate Swing Bed (ISB) on 12/23/21 for custodial care with a diagnosis of generalized weakness and Osteoarthritis of knee.

Review of Patient 4's Restorative Care Plan (undated), showed the following:

Problem: Potential for injury due to poor balance, falls, and a hazardous environment. Goal: To prevent falls and identify any possible environmental hazards. Interventions: Encourage patient to exercise with Restorative Aide regularly, or to perform other activities that promote balance, such as walking; Encourage patient to wear proper fitting footwear; Observe the patient's ability to ambulate and whether the patient uses assistive device. Outcome: Patient will remain free of falls, and any fall related injuries. Notes: No changes dated 02/22/23 Reviewed by Staff Q, CNA on 02/22/23.

Further review of Patient 4's medical record failed to show documented evidence Patient 4's care plan was updated after the patient fell on the following dates and times: 03/08/23 at 2:15 AM; 03/23/23 at 10:10 AM; 04/19/23 at 1:30 PM.


Patient 6

Review of Patient 6's active medical record showed that Patient 6 was admitted to Intermediate Swing Bed (ISB) on 05/01/20 for custodial care with a diagnosis of dementia and hypertension (increased blood pressure).

Review of Patient 6's Restorative Care Plan (undated), showed the following: Problem: Potential for injury due to poor balance, falls, and a hazardous environment. Goal: To prevent falls and identify any possible environmental hazards. Interventions: Encourage patient to exercise with Restorative Aide regularly, or to perform other activities that promote balance, such as walking; Encourage patient to wear proper fitting footwear; Observe the patient's ability to ambulate and whether the patient uses assistive device. Outcome: Patient will remain free of falls, and any fall related injuries. Notes: No changes dated the following: 10/12/22; 12/06/22; 02/09/23 and 04/12/23 Reviewed by Staff Q, CNA on the following dates: 10/12/22; 12/06/22; 02/09/23 and 04/12/23.

Further review of Patient 6's medical record failed to show documented evidence that Patient 6's care plan was updated after the patient fell on the following dates: 06/26/22 and 11/25/22.

Review of Patient 6's Restorative Care Plan (undated), showed the following: Problem: High risk for falls, related to being unaware of safety needs, poor communication/comprehension, gait/balance problems, and incontinence
Goal: Prevent falls, and promote patient safety. Interventions: Encourage patient to perform ADLs such as hair combing, dressing, using the bedside commode or toilet; anticipate and meet needs; always keep call light within reach of patient; promptly answer any call lights. Outcome: Patient will remain free of falls, and any fall related injuries. Notes: No changes dated the following: 10/12/22; 12/06/22; 02/09/23 and 4/12/23. Reviewed by Staff Q, CNA on the following dates: 10/12/22; 12/06/22; 02/09/23 and 04/12/23.

Further review of Patient 6's medical record failed to show documented evidence that Patient 6's care plan was updated after the patient fell on the following dates: 6/26/22 and 11/25/22.


Patient 7

Review of Patient 7's discharged medical record showed Patient 7 was admitted to Intermediate Swingbed (ISB) on 05/01/20 for custodial care with a diagnosis of quadriplegic spinal paralysis (damage to the spinal cord), neurogenic bowel and bladder (failure of nerve to communicate to bowel and bladder), orthostatic hypotension (decrease in blood pressure upon sitting up), long term use of anticoagulants (medication used to thin blood), chronic supra pubic catheter (medical device inserted above supra pubic bone to allow urine elimination), depression and anxiety.

Review of a document titled, "Provider Progress Notes," dated 02/26/23 at 3:19 PM identified Patient 7 at risk for aspiration (situation when oral contents enter the lungs) secondary to spinal paralysis.

Review of Patient 7's care plan dated 03/29/23 failed to show documented evidence that nursing staff included risk for aspiration on the care plan for Patient 7.

During an interview on 05/04/23 at 9:17 AM, Staff X, Physician Assistant (PA) stated, " ...I had taken care of this patient since 2020 as a locum (temporary staff) and he had a significant history of aspiration due to being a quadriplegic. He had been intubated at least yearly and in ICU (Intensive Care Unit) for aspiration pneumonia ..."


Patient 8

Review of Patient 8's active medical record showed Patient 8 was admitted to Intermediate Swingbed (ISB) on 05/01/20 for custodial care with a diagnosis of hypertension (elevated blood pressure), depression, and anemia (low red blood cells). On 04/30/23 at approximately 1:30 PM, Patient 8 had a reported suicide attempt.

Review of Patient 8's care plan showed a nursing note dated 04/30/23 and 05/01/23 that documented Patient 8's suicide attempt. Nursing staff failed to update the plan of care to implement suicide prevention interventions and goals such as increased monitoring, physical and mental assessments, medication review, and or consultations.

Based on observation and interview the Critical Access Hospital (CAH) failed to ensure a clean and sanitary environment was maintained for nine of nine patients (Patients 1, 2, 3, 4, 5, 6, 7, 8 and 9) reviewed as evidenced by the failure of staff to perform hand hygiene after direct patient contact, staff laying on floor in patient care areas, and failure to use an ice scoop to fill patient cups.

The hospital's failure to maintain a clean and sanitary environment for nine of nine patients (Patients 1, 2, 3, 4, 5, 6, 7, 8 and 9) reviewed places any patient receiving services at this hospital at risk for exposure to infectious diseases.

Findings Include:

During a video observation dated 04/07/23 at 3:04 AM, two unidentified staff were observed scooping ice with patient cups without the use of gloves or ice scoop. Further review of the video shows staff distributing the dirty cups to patient rooms.

During an observation on 04/25/23 at 8:21 AM, the medication cart was sitting in the dining area with an opened container of applesauce with no date or time of opening on the container. At the same time, Staff were seen assisting patients with feeding and not performing hand hygiene between patient interactions.

During a video observation dated 04/30/23 at 2:33 PM, one unidentified staff was observed scooping ice with patient cups without the use of gloves or ice scoop. Further review of the video showed staff distributing the dirty cups to patient rooms.

During an interview on 05/04/23 at 1:30 PM Staff C, LPN stated, "staff have been told not to do this multiple times and have been provided an ice scoop."

During a video observation dated 04/30/23 at 3:49 PM, two unidentified staff were observed sitting/laying on floor on the east hall for approximately 20 minutes socializing with other staff and an unidentified patient. Staff did not perform hand hygiene after getting up from the floor.

Based on policy review, record review, observation and interview the Critical Access Hospital (CAH) failed to ensure patient care was provided in a safe setting for six of nine high fall risk patients reviewed (Patients 2, 3, 4, 5, 6, and 8) as evidenced by the failure to properly identify patients at high risk for falls, the failure to implement fall interventions and the failure to implement a policy and procedure for suicidal ideation and/or attempted suicide.

Failure to identify patients at high risk for falls, implement fall interventions, and implement a policy and procedure for suicidal ideation and/or attempted suicide, places all patients receiving services at this hospital at risk for serious falls with injury or successful suicide attempts.

Findings Include:

The Critical Access Hospital (CAH) failed to properly identify patients at high risk for falls, implement fall interventions, and implement a policy and procedure for suicidal ideation and/or attempted suicide resulting in unsafe care for six of nine patients reviewed (Patients 2, 3, 4, 5, 6, and 8) and places any patient receiving services at this hospital at risk for falls with injury or successful suicide. Refer to tag C2523.

Based on policy review, record review, observation and interview the Critical Access Hospital (CAH) failed to ensure patient care was provided in a safe setting for six of nine high fall risk patients reviewed (Patients 2, 3, 4, 5, 6, and 8) as evidenced by the failure to properly identify patients at high risk for falls, the failure to implement fall interventions and failure to implement a policy and procedure for suicidal ideation and/or attempted suicide.

The Hospital's failure to properly identify patients at high risk for falls, implement fall interventions, and implement a policy and procedure for suicidal ideation and/or attempted suicide resulted in unsafe care for six of six patients (Patients 2, 3, 4, 5, 6, and 8) and places any patient receiving services at this hospital at risk for serious injury or fall with harm or successful suicide attempts.

Findings Include:

Review of a Hospital policy titled, "Fall Assessment Policies and Procedures," revised 1/10/22 showed, "A Fall Assessment will be completed during admission to [The Hospital] on patients to determine those at a high risk for falling in order to initiate appropriate fall precautions ...During the admitting shift, the ISB [Intermediate Swing Bed] Supervisor will complete the Morse Fall Risk (tool used to measure patients at high risk for falls) Section on the Admission Assessment ...on all patients admitted to [The Hospital] ..." The policy showed that the Morse Fall Scale requires evaluation of the following: history of falls; secondary diagnosis; use of ambulatory aides; presence of IV (intravenous) or IV access; gait; and mental status. A Morse Fall Scale score of 0-44 indicates a low/moderate risk and a score of 45 or greater indicates a high-risk level for falls. " ... If patient is at Low/Moderate Risk or High Risk, fall precautions will be implemented ... ISB Unit-

1. Place "YELLOW CIRCLE WITH L" on the patient indicator plaque outside the patient's door frame for Low/Moderate Risk.

2. Place "YELLOW CIRCLE WITH H" on the patient indicator plaque outside the patient's door frame for High Risk.

3. Charge Registered Nurse (RN) (Acute Unit) or RN/licensed Practical Nurse (LPN) (ISB unit) will reassess fall risks using the Fall Risk Scale Morse ...during patient's stay if feels patient's condition warrants reassessment.

4. If the Standard Fall Prevention Interventions or the High-Risk Fall Prevention Interventions are not effective, consult attending practitioner or practitioner on call for recommendations. Standard Fall Prevention Interventions:
Patients who are scored "LOW/MODERATE RISK" on the Morse Fall Scale (score of 0-44) will have the following interventions implemented by the Nursing Staff: Direct Care: Nursing Staff
o Assess patient's fall risk upon admission and during patient's stay if feels patient's condition warrants reassessment.
o Assign the patient to a bed that enables the patient to exit toward his/her stronger side whenever possible.
o Assess the patient's coordination and balance before assisting with transfer and mobility activities.
o Use gripper socks for patients.
All Staff:
o Approach patient towards unaffected side to maximize participation in care.
o Transfer patient towards stronger side.
Education:
o Actively engage patient and family in all aspects of Fall Prevention Program.
o Instruct patient in all activities prior to initiating assistive devices.
o Teach patient use of grab bars
o Instruct patient in medication time/dose, side effects, and interactions with food/medications.
Environment:
o Place patient care articles within reach.
o Provide physically safe environment (eliminate spills, clutter, and unnecessary equipment).
o Provide adequate lighting.
Equipment:
o Lock all moveable equipment before transferring patients.
o Individualize equipment specific to patient needs.
o Bed in low position for patient.
o When patient is in bed, raise top section of ½ rails.
o Call light placed within patient's reach.
High Risk Fall Preventions Interventions:
Patients who are scored "HIGH RISK" on the Morse Fall Scale (score of 45) will have the following interventions implemented by the Nursing Staff. Nursing Staff Direct Care:
o Assess patient's fall risk upon admission and change in status.
o Assign the patient to a bed that enables the patient to exit toward his/her stronger side whenever possible.
o Assess the patient's coordination and balance before assisting with transfer and mobility activities.
o Use gripper socks for patients.
Additional Direct Care may be used if needed: (determined by the charge nurse.)
o 30-minute check list as needed
All Staff:
o Approach patient towards unaffected side to maximize participation in care.
o Transfer patient towards stronger side.
Education:
o Actively engage patient and family in all aspects of Fall Prevention Program.
o Instruct patient in all activities prior to initiating assistive devices.
o Teach patient use of grab bars
o Instruct patient in medication time/dose, side effects, and interactions with food/medications.
Environment:
o Place patient care articles within reach.
o Provide physically safe environment (eliminate spills, clutter, and unnecessary equipment).
o Provide adequate lighting.
o Clear patient environment of all hazards
o Move patient closer to the nurse's station if possible.
Equipment:
o Lock all moveable equipment before transferring patients.
o Individualize equipment specific to patient needs.
o Bed in low position for patient.
o When patient is in bed, raise top section of ½ rails
o Call light placed within patient's reach
o If patient has an alternation in physical mobility:
1. Gait belt will be used when patient is transferring or ambulating
2. SBA by staff when patient is transferring or ambulating
o If patient is confused or non-compliant:
1. When patient is in bed, activate bed alarms.
2. When patient is in chair or wheelchair, activate chair alarms.
Additional Equipment may be used listed below: (determined by the charge nurse)
o Lab buddy/Velcro Strap when the patient is up in a wheelchair.
o Nonskid tape strips in front of the patient's chair and/or bed.
o Fall mat bedside the bed and/or chair.
o Low Bed"

Review of a hospital policy titled, "Fall Follow-Up Guidelines Policy & Procedure," revised 12/21, showed, "Documentation At Time of Fall:
1. Document what the patient was doing at time of fall, where the fall occurred, any related factors, the assessment of the patient and if the fall was witnessed or unwitnessed ... 4. Fill out the Nurse Fall Worksheet and give to either the Director of Nursing on Acute Unit or ISB Supervisor on ISB unit ...6. ISB Unit-Fill out the blue "Follow-up Required on Falls and New Admission/Re-Admission" form ... Falls will be followed up every shift for 72 hours utilizing the following guidelines: 1. Post Fall Assessment form-sections-Vital Signs: Pain Assessment: Additional Pain: Neurologic Signs: Glasgow Coma: Details every shift for 72 hours, describing patient's condition and whether patient has any complaints related to fall. 2. If head injury occurred or if fall was unwitnessed: Neuro checks initially at time of fall: 30 minutes x 2: 1 hour x 4: then every shift x 5 or as ordered by Practitioner ..."

Review of a document titled, "Incident Report," dated 4/24/22 through 4/24/23 showed that the hospital has had a total of 35 patient falls within the last year."


Patient 2

Review of Patient 2's discharged medical record showed that Patient 2 was admitted to Intermediate Swing Bed (ISB) on 09/15/21 for custodial care with a diagnosis of dementia and self-care deficit with history of falls. On 04/20/23, Patient 2 was discharged/transferred to another hospital for a psychosocial assessment/evaluation for progressing behavioral issues.

Review of a "History and Physical," dated 12/21/22, showed that Patient 2 had four unwitnessed, non-injury falls within the past year and slowly progressing dementia.

Review of the hospital's incident log dated 04/08/22 - 04/22/23 showed that Patient 2 had two falls; 09/09/22 and 11/02/22.

However, review of the medical record showed that during the same time period 04/08/22 - 04/22/23 Patient 2 had six falls on the following dates and times: 09/19/21 at 7:35 AM; 10/23/21 at 4:10 AM; 10/27/21 at 4:45 AM; 11/02/2022 at 1:55 PM; 09/09/22 at 3:00 PM; 03/20/22 at 2:35 PM.

Review of Patient's 2's Morse Fall Risk Assessment failed to show documented evidence that a weekly fall risk assessment was completed on the following dates:
11/11/21 to 12/01/21; 02/08/22 to 03/20/22; 03/21/22 to 04/12/22; 06/09/22 to 09/09/22; 10/05/22 to 01/02/22; 12/07/22 to 12/28/22; 02/01/23 to 03/01/23; 03/01/23 to 03/22/23; 03/22/23 to 04/12/23.

On 09/19/21 at 12:04 PM, Staff K, LPN documented that Patient 2 had a non-injury fall. Review of the medical record failed to show documented evidence that Staff K completed a Morse Fall Risk Assessment after Patient 2's fall. Further review showed the next fall risk assessment was not completed until 09/22/21 (3 days after fall) by Staff L, RN, and indicated that Patient 2 had no history of falls in the past three months. Staff L's failure to correctly complete the fall risk assessment resulted in a fall risk score of 30 (incorrectly indicating a low risk for falls.)

Review of a "Post Fall Assessment," performed by Staff K, LPN on 09/19/21 at 7:45 AM, showed, " ...Date, Time of Fall : 09/19/2021 7:35 CDT [7:35 AM] ...Fall Witness : Unwitnessed ... At 0735, Certified Nurse Aide (CNA) summoned this writer into patient room stating the patient was on the floor. On arrival, this writer noted patient to be laying on the floor on her back. CNA stated when she noted patient on the floor, she was sitting in the upright position on her bottom. Patient denied LOC [loss of consciousness], hitting her head, pain, tingling, etc. Patient stated she was picking up cat litter off the floor from her cat (which stays in her room), lost her balance and fell backwards on her bottom. Patients rolling walker was found next to her tipped over on the floor. Patient had on her nightgown, and black sandals with no socks. Patient stated she was dizzy while sitting on the floor but subsided after a few seconds of rest. Patient was assessed and then transferred x 2 staff members to her chair. No apparent injuries noted. Neuro assessments to be performed per post fall protocol. Patient will be placed on 30-minute visual checks x 72 hours per post fall protocol. Post Fall Status : No change from baseline." Further review of the medical record failed to show documented evidence that neurological checks and post fall assessments were completed at the frequency and intervals required per hospital policy.

On 09/19/21 at 12:04 PM, Staff K, LPN documented Patient 2's non-injury fall. Review of the medical record failed to show documented evidence that Staff K completed a Morse Fall Risk Assessment after Patient 2's fall. Further review showed the next fall risk assessment was not completed until 09/22/21 (3 days after fall) by Staff L, RN, and indicated that Patient 2 had no history of falls in the past three months. Staff L's failure to correctly complete the fall risk assessment resulted in a fall risk score of 30 (incorrectly indicating a low risk for falls.)

Review of a "Post Fall Assessment," performed by Staff O, LPN on 10/23/21 at 4:10 AM, showed, " ...Date, Time of Fall : 10/23/2021 4:10 CDT ...Fall Witness : Unwitnessed ... This nurse was notified by CNA that resident was on floor. Upon entering room resident was sitting on buttocks on floor beside bed facing window. Walker was behind resident. Bedside table in front of resident. Lights in room were on. Shoes were partially on resident's feet. Floor was dry. When asked what had happened resident had a difficult time explaining. Resident stated she had been to the bathroom and was walking back to bed when her feet slid on floor, and she fell landing on buttocks. Resident states she was not using walker correctly and was not wearing shoes properly. Verbalized no pain and that she did not hit head. Neuros initiated. Vitals taken ...Assisted off floor by CNA's and into bed. Staff prompted resident to use call-light when needing assistance. Call light within reach. Physician notified of non-injury fall. Follow facility fall protocol per physician. Day shift nurse will notify family ..." Further review of the medical record failed to show documented evidence that neurological checks and post fall assessments were completed at the frequency and intervals required per hospital policy.

On 10/23/21 at 5:10 AM, Staff O, LPN, documented Patient 2's non-injury fall. Review of the medical record failed to show documented evidence that Staff O completed a Morse Fall Risk Assessment after Patient 2's fall. Further review showed the next fall risk assessment was not completed until Patient 2 had another fall on 10/27/21 (4 days after fall).

Review of a "Post Fall Assessment," performed by Staff C, LPN on 10/27/21 at 6:38 AM, showed, " ...Date, Time of Fall : 10/27/2021 4:45 CDT ...Fall Witness : Unwitnessed ...Patient stated that she was trying to take care of the cat. She did not know where the cat was (it was in the kennel) and wanted to find it some food (which is by the litter box). Patient was found sitting on her coccyx on the floor by the foot of her bed, feet towards the bed. Lotion was noted to be on the door of the cat's kennel and the bottle of lotion was sitting next to the patients chair. Patient stated that she had not been on the floor long. Her call light was within reach, but she did not use it. During her assessment the patient commented that she is unable pick up her cat and put her on the chair. Denies pain/discomfort during assessment. Earlier in the night around 0200 [2:00 AM] the patient was looking for her parents and wondered if they were worried about her and if they had her cat. This writer assured her that her family knew where she was and that she was staying the night with us and informed her that her cat was sleeping on her bed. Vitals charted in I-View. The day nurse will notify practitioner and family during business hours."

On 10/27/21 at 6:38 AM, Staff C, LPN, documented Patient 2's non-injury fall. Review of the medical record showed that Staff C, LPN, entered Morse Fall Risk Assessment on 10/27/21 at 4:45 AM. Staff C failed to complete the assessment with the following required information: presence of secondary diagnosis; IV/Heparin Lock; gait weak or impaired; mental status; Morse Fall Risk Score; and participative in fall prevention. Further review of the medical record failed to show documented evidence that neurological checks and post fall assessments were completed at the frequency and intervals as required per hospital policy.

Review of a "Post Fall Assessment," performed by Staff T, LPN on 3/20/22 at 3:00 PM, showed, " ...Date, Time of Fall : 3/20/22 at 14:35 CDT [2:35 PM] ...Fall Witness : Unwitnessed ... CNAs were passing snack cart down her hall and heard chair alarm sounding. Door to her room was closed but not latched. Found pt [patient] prone on floor with feet by sink and head in front of recliner. Denies injury. Rolled onto her back, assisted to sitting, gait belt applied and stood with 2 staff. Assisted into bathroom where she did not have either a BM [bowel movement] or void. Assisted to bed. Gait steady. Continues to deny injury. VS [vital signs] and Neuros WNL [within normal limits]. Left message with acute nurse for [Physician]. Further review of the medical record failed to show documented evidence that neurological checks and post fall assessments were completed at the frequency and intervals required per hospital policy.

On 03/21/22 at 10:05 PM, Staff R, LPN, documented Patient 2's Morse Fall Risk Assessment as no history of falls in the last three months (one day after Patient 2 fell) resulting in an incorrect fall risk score.

Review of a "Post Fall Assessment," performed by Staff J, LPN on 09/09/22 at 4:07 PM, showed, " ...Date, Time of Fall : 09/09/22 at 15:00 CDT [3:00 PM] ...Fall Witness : Unwitnessed ... Aides called this nurse to patient's room at 1500 [3:00 PM], patient was laying straight in front of chair like they slid off of the seat. Patient stated, "I was in my chair, trying to sit it up, and I slid right out." Denies hitting head. Provider on call notified, gave orders (see nurse note) also gave order to D/C aspirin permanently. Daughter Val notified, denies questions. This nurse attempted to obtain patient vitals post fall, patient stated, "Get this thing off me, well you're going to." Provider aware of VS [vital signs] and Neuro refusal." Further review of the medical record failed to show documented evidence that neurological checks and post fall assessments were completed at the frequency and intervals required per hospital policy.

On 09/09/22 at 3:00 PM, Staff J, LPN, documented Patient 2's Morse Fall Risk Assessment at the time of Patient 2's fall. Staff J, LPN incorrectly updated the fall risk assessment to reflect no history of falls in the past three months. On 09/14/23 at 8:16 AM, Staff J, LPN, documented another Morse Fall Risk Assessment and again incorrectly documented no history of falls in the last three months. The failure of Staff J, LPN to correctly document a history of falls resulted in an incorrect fall risk score for Patient 2.

Review of a "Post Fall Assessment," performed by Staff L, RN on 11/02/22 at 2:10 PM, showed, " ...Date, Time of Fall : 11/02/22 at 13:55 CDT [1:55 PM] ...Fall Witness : Unwitnessed ... No apparent injuries from fall. Patient Statement Related to Fall : I wanted to go to bed and I didn't want to use the call light." Further review of the medical record failed to show documented evidence that neurological checks and post fall assessments were completed at the frequency and intervals required per hospital policy.

Review of the Morse Fall Risk Assessment from admission on 09/15/21 to discharge/transfer on 4/20/23 showed egregious inconsistencies and inaccurate documentation related to the following; History of Fall in Last 3 Months; Use of Ambulatory Aids; Gait Weak or Impaired; and Mental Status. The failure of nursing staff to accurately document all aspects of the Morse Fall Risk Assessment resulted in the inaccurate scoring of Patient 2's fall risk throughout the hospitalization.

Review of Patient 2's Restorative Care Plan (undated), showed the following: Problem: Potential for injury due to poor balance, falls, and a hazardous environment. Goal: To prevent falls and identify any possible environmental hazards. Interventions: Encourage patient to exercise with Restorative Aide regularly, or to perform other activities that promote balance, such as walking; Encourage patient to wear proper fitting footwear; Observe the patient's ability to ambulate and whether the patient uses assistive device. Outcome: Patient will remain free of falls, and any fall related injuries.

Problem: High risk for falls related to being unaware of safety needs, poor communication/comprehension, gait/balance problems, and incontinence. Goal: Prevent falls and promote patient safety. Interventions: Encourage patient to perform ADLs such as hair combing, dressing, using the bedside commode or toilet; Anticipate and meet needs; Always keep call light within reach of patient; Promptly answer any call lights. Outcome: Patient will remain free of falls and fall related injuries.

Problem: Potential for falls, out of bed, or out of chair.
Goal: Promote patient safety and reduce the risk of fall related injuries.
Interventions: Chair alarm in wheelchair or recliner to alert staff of patient rising unassisted ...monitoring tools in place for proper documentation; Bed alarms while patient is in bed to alert staff of patient rising unassisted ...monitoring tools in place for proper documentation; Bed in low position.
Outcome: No falls or fall related injuries after implementing the above interventions.

Staff L, RN, reviewed Patient 2's Care Plan on 10/05/21 (16 days after Patient 2's fall on 09/19/21) and stated, "Reviewed and will continue with plan." Staff L, RN did not address Patient 2's fall in the care plan and no revisions were made to the plan of care to address goals not being met or the addition of additional interventions to prevent falls.

An undated and unsigned note on the care plan showed the following, "The patient fell on 10/23/21 and again on 10/27/21, UA collected due to increased confusion on 10/27/21. The urine sent out for a C&S. Cipro started on 10/29/21 500mg PO Daily for 5 days. No injuries for either fall." Staff L, RN made no revisions to the fall interventions.

On 12/08/21, Staff L, RN stated, "Bed and chair alarms placed on the patient due to unstable walking and to remind her to seek assistance in transfers/ambulation. Reviewed and updated." (Chair and bed alarms were already included in the plan of care.) Staff L, RN made no further revisions to fall interventions.
On 01/27/22, Staff L, RN wrote on the care plan, "Reviewed will continue with plan."
On 02/03/22, Staff L, RN wrote on the care plan, "Reviewed and will continue with plan."

Review of Patient 2's Care Plan dated 04/20/23, showed the following, " ...[Patient 2] will remain free from fall-related injuries throughout the next 60 days ...Staff will assist [Patient2] with a transfer or walking with one or two-staff assist walker and gait belt. Staff will watch [Patient2] for signs and symptoms of fatigue and offer to assist her with the wheelchair ...Staff will assist [Patient 2] with all elimination needs. [Patient 2] doesn't always ask to use the bathroom, staff will offer to taker her before and after meals and activities, and when she wakes up from sleeping ...Staff will assist with all ambulating. Staff will assist with all toileting needs ...Staff will do a fall assessment monthly and with a fall. [Patient 2] has a chair and bed alarm to help alert staff if she is trying to get up unassisted. [Patient 2] may use ½ side bed rail, if desired, for safety, &/or for repositioning & transfers while in bed ..."
On 4/14/23 the Care Plan Meeting Notes/Updates showed, "No significant changes at this time ..." Nursing staff failed to address any of Patient 2's falls with revisions to fall risk interventions or goals to address Patient 2's numerous falls throughout her hospitalization.

Review of an order, "Physical Therapy Evaluation and Treatment Outpatient," dated 12/09/21 and discontinued on 04/20/23, showed, "patient has pain in feet, back and right hip when walking."

Review of an order, "Physical Therapy Evaluation and Treatment Outpatient," dated 04/28/22 and discontinued on 04/20/23, showed, "Evaluate the patient's feet due to turning in and the patient is walking on the side of her foot."

Review of Patient 2's medical record failed to show documented evidence that Patient 2 received a physical therapy evaluation or services at any time during Patient 2's hospitalization.

Review of Patient 2's medical record failed to show documented evidence that Patient 2 received an evaluation or services for physical therapy from 12/09/21 through 04/20/23 as ordered.



Patient 3

Review of Patient 3's active medical record showed that Patient 3 was admitted to Intermediate Swing Bed on 05/13/21 for custodial care with a diagnosis of cognitive impairment, dementia, and hypertension.

Review of a "History and Physical," dated 05/13/21, showed that Patient 3 suffered from anxiety, sundowner syndrome, PTSD, and dementia with hallucinations. Patient 3 had a recent MRI of the lumbar spine that showed spine degeneration and required a cane for ambulation.

Review of a "Correspondence Phone Message/Call," dated 08/18/22 at 10:30 AM, showed a message from Staff C, LPN to Staff H, APRN that stated, "Family declined the spine specialist and pain management. Would do the lidocaine patch and muscle relaxant and physical therapy you suggested." Further review of Patient 3's medical record failed to show any provider orders or other communication in regard to obtaining physical therapy for Patient 3 from time of admission to current.

Review of Patient 3's medical record showed that Patient had three falls on the following dates and times: 12/13/22 at 11:15 PM; 02/12/23 at 3:08 PM; and 04/05/23 at 11:20 AM.

Review of Patient's 3's Morse Fall Risk Assessment failed to show documented evidence that a weekly fall risk assessment was completed on the following dates:
05/09/22 to 5/30/22; 5/30/22 to 07/04/22; 07/04/22 to 07/18/22; 07/18/22 to 08/01/22; 09/05/22 to 10/10/22; 10/10/22 to 10/24/22; 11/07/22 to 11/28/22; and 12/16/22 to 01/23/23.


Review of a "Post Fall Assessment," performed by Staff S, RN, on 12/13/22 at 12:00 AM, showed, " ...Environmental Safety in Place at Time of Fall : Bed in low position, Call device within reach, Mobility support items readily available, Non-Slip footwear, Personal items within reach, Traffic path in room free of clutter, Upper/Half length side rails for bed mobility, Wheels locked. Evaluation of Injury Based Upon Interventions : No apparent injuries from fall. Nursing Progress Note : No new changes to residents health status. Post Fall Status : No change from baseline." Staff S, RN, failed to show documented evidence of the following as required per hospital policy: date and time the fall occurred, what the patient was doing at time of fall, where the fall occurred, any related factors; if fall was witnessed/unwitnessed; Assessment that included: vital signs, pain, neurologic signs, Glasgow Coma, and notification of the practitioner and patient's family of the fall.

Review of a follow-up "Post Fall Assessment," performed by Staff S, RN on 12/13/22 at 11:30 PM, showed, " ...Date, Time of Fall : 12/13/2022 23:15 CST [11:15 PM]; Fall Witness: Unwitnessed; Fall Assist : Unassisted; Location of Fall : Bathroom; Activity at Time of Fall: Bedrest; Special Conditions at Time of Fall : First time out of bed; Environmental Safety in Place at Time of Fall : Bed in low position, Call device within reach, Mobility support items readily available, Night light, Non-Slip footwear, Personal items within reach, Sensory aids within reach, Upper/Half length side rails for bed mobility, Wheels locked; Evaluation of Injury Based Upon Interventions : Minor; Patient Statement Related to Fall : pt [patient] stated that she was going into the room to look for something, but could not figure out what; Date/Time Family or Rep Notified : 12/13/2022 23:25 CST [11:25 PM]; Name of Family Member Notified :[name]; Physician Comm Date & Time 1 : 12/14/2022 0:30 CST [12:30 AM]; Physician Notified 1 : [Provider]; Nursing Progress Note : Nurse's Aide found resident on floor in whirlpool rm [room] @ 2320 [11:20 PM] and informed the Nurse [Staff S, RN] pt [patient] states she was trying to find something but slipped on top of a trashcan and bumped her ankle, knee and hip on the way down. pt complained of mild pain to her RLE [right lower extremity], ROM [range of motion] done to all extremities WNL [within normal limits]. pt stood and transferred to wheelchair then to bathroom with ease. Family member notified @ 2325 [11:25 PM]. VS [vital signs] taken @ 2330 [11:30 PM]; temp 36.8, HR [heart rate] 82, Resp [respirations] 18, BP [blood pressure] 158/83, O2 [oxygen saturation] 94%. PERRLA [pupils equal, round, reactive to light and accommodation], alert, confused, no new changes in cognitive function. neuros and vitals done as ordered. Notified and left message with on-call PCP [primary care provider] @ 0030 [12:30 AM]. Pt [patient] is now in bed and does not complain of any pain at this time. Pt has slight swelling to rt [right] ankle but shows no signs of bruising. Will continue to monitor and assess as needed; Post Fall Status : No change from baseline."

Review of the post fall assessment showed that Staff S, RN, documented that Patient 3 was in the bathroom and activity was bedrest at the time off the fall. Staff S, RN, then documented that Patient 3 was found in the whirlpool room at the time of fall and had been ambulating when she bumped into a trashcan injuring her right lower extremity during the fall.

Review of the post fall assessments showed that Staff S, RN documented the first "Post Fall Assessment" 23 hours and 15 minutes prior to Patient 3's fall. The documentation also showed that Staff S, RN documented no injury to Patient 3 on the first post fall assessment. Review of Staff N's documentation of Patient 3's fall is inconsistent in it's timeline and description of events, raising question to the validity of its content. Further review of the medical record failed to show documented evidence that neurological checks and post fall assessments were completed at the frequency and intervals required per hospital policy.

Review of a "Post Fall Assessment," performed by Staff I, LPN, on 02/12/23 at 3:08 PM, showed that Staff I, RN, failed to show documented evidence of the following as required per hospital policy: date and time the fall occurred, what the patient was doing at time of fall, where the fall occurred, any related factors; and notification of the practitioner and patient's family of the fall. Further review of the medical record failed to show documented evidence that neurological checks and post fall assessments were completed at the frequency and intervals required per hospital policy. Review of the medical record showed additional "Post Fall Assessments," performed on 02/13/23 at 2:04 AM; 02/13/23 at 1:25 PM; and 02/13/23 at 10:15 PM that failed to show documented evidence of when Patient 3's fall occurred and other pertinent information as required per hospital policy. Further review of the medical record showed a notation in Patient 3's Plan of Care that showed, " ...02/11/23 Patient found on floor, returning from bathroom. No injuries ..."

Review of a "Post Fall Assessment," performed by Staff F, LPN, on 04/05/23 at 11:20 AM, showed, " ...Date, Time of Fall : 04/05/2023 11:20 CDT; Fall Witness : Witnessed; Location of Fall : Other: Near miss fall - dining room; Activity at Time of Fall : Ambulating; Special Conditions at Time of Fall : Other: just stood up from chair after napping for 2 hours; Environmental Safety in Place at Time of Fall : Mobility support items readily available, Non-Slip footwear, Personal items within reach, Sensory aids within reach, Traffic path in room free of clutter; Evaluation of Injury Based Upon Interventions : No apparent injuries from fall".

Review of the post fall assessment failed to show documented evidence that Staff F, LPN, notified the provider or Patient 3's family that a fall had occurred. Further review of the medical record failed to show documented evidence that neurological checks and post fall assessments were completed at the frequency and intervals required per hospital policy.

Review of the Plan of Care for Patient 3, dated 07/21 and updated 08/21, showed that Patient 3 had a potential for injury related to falls, secondary to; age of 65 years or older; use of assistive device for mobility; diminished mental status; impaired balance; neuropathy; and an injury fall that occurred 12/13/22 and a non-injury fall that occurred 02/11/23. Interventions listed on the Plan of Care included the following: Encourage patient to exercise regularly or other activities that improve balance; Instruct patient to rise slowly from sitting or lying position; Clutter free environment; Clean floor spills immediately; Keep items within reach; Bed in lowest position; Call light within reach; non-skid footwear/slippers; Use of eyeglasses; Assessment of mental status changes; Assessment of medications that may contribute to falls including hypnotics, diuretics, nitrates, antihypertensives, antidepressants, and digitalis. Outcome stated that Patient 3 will remain free from fall related injuries throughout the next 60 days.
It was noted on the Plan of care that, "The patient does not want the side rails up." The care plan also noted that Patient 3 will forget to use her cane and needed to be reminded or have it retrieved for her. Patient 3 was noted to work with the Restorative Aid for regular exercise.

Review of an update to the Plan of Care dated 02/01/23 showed that Patient 3 would be started on Fentanyl (a narcotic medication used for pain control with side effects that may include sedation, confusion, and dizziness which may increase fall risk) 12mcg/hour patch for pain effective 02/03/23. On 2/15/23 the Fentanyl patch dosage was increased to 25 mcg/hour effective until 02/18/2