HospitalInspections.org

Based on record review and interview the governing body failed to assure that hospital services were provided in compliance with the Medicare Conditions of participation by failing to take actions through the hospital's QAPI program to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities. Findings:

(cross reference findings at A0119, A0267, A0274, A0275, A0276, and A0289)

Based on observation, record review and interview the hospital failed to meet the Conditions of Participation of Patient Rights by:

1) failing to ensure care in a safe setting as evidenced by the hospital's failure to follow policy and procedure for patients who are at risk for falls, failing to initiate or update approaches after a patient falls to prevent future falls and injuries, and failing to initiate incident reports for each patient fall in order for Quality Assurance to track these incidents, determine the probable cause of falls, and implement plans to correct. (see findings at A0144 and A0145)

2) failing to identify patients at high risk for falls by failing to accurately assess a patient with a recent history of a fall which resulted in the patient not being identified as a High Risk for Falls and sustaining a fall on the day of admission for 1 of 5 sampled patients. (#5) . (see findings at A0144)

3) failing to identify patient behaviors placing them at high risk for injury by failing to follow hospital policy to implement care plan changes and monitor the effectiveness of those interventions by having a patient who had already fallen once in the hospital found by multiple staff members attempting to climb over the four raised side rails multiple times without taking immediate, effective corrective action to prevent the patient from harming herself which resulted in the patient falling again for 1 of 5 sampled patients. (#5) (see findings at A0144)

4) failing to notify the physician responsible for the care of a patient of a fall and failing to accurately document the events of a patients fall when the patient struck her head for 1 of 5 sampled patients. (#4) (see findings at A0144)

5) failing to ensure patients admitted to the psychiatric unit (Unit 54) were allowed personal privacy and dignity as evidenced by moving all patient beds into the hallway during the night shift for patients that required LOS-- (Line of Sight), 1:1 and/or High Fall Risk (HRF) management due to inadequate staffing at night to maintain the LOS/1:1/HRF for 21 of 21 patients on Unit 54. (see findings at A0143)

6) failing to fill out incident reports required by hospital policy to accurately identify adverse patient events for 2 of 5 patients (#4, #5). (see findings at A0144)

7) failing to provide adequate staff to ensure 1:1 direct patient observation for patient safety as ordered by the physician resulting in a fall for a patient who climbed over the side rails in the absence of the 1:1 supervision resulting in injury for 1 of 5 sampled patients. (#5); and failing to ensure adequate staffing to maintain an ordered observational level of LOS (line of sight) for 1 of 5 sampled patients (#4). (see findings at A0144 and A0145)

8) failing to ensure restraints were not used for staff convenience and without physician order by restraining patient #5 and #2 and patient #5 without a physician's order by raising all four side rails.

9) failing to ensure the hospital's governing body delegated the responsibility for the effective operation of the grievance process as evidenced by the hospital failing to follow the hospital's policies and procedures relative to the grievance process when the hospital receives a grievance. (see findings at A0119)



An Immediate Jeopardy situation was called on 04/15/10 at 5:10 p.m. Present were S1Administrator; S2DON; S3MD, VPMA; and S4RN, Asst. Admin. Operations. The Immediate Jeopardy situation was the result of the following:

The facility failed to 1) Ensure that hospital staffing meets the needs of the patients identified as high risk for falls and/or needing increased observation status which resulted in:

a) Failing to follow Physician Orders for maintaining a patient on one-to-one observation status to prevent falls resulting in injury to patient #5's left hip, failing to keep patient #4 in line-of-sight observation resulting in a fall with head injury, failing to provide ambulation assistance to patient #3 resulting in a fall with a leg fracture, failing to ensure patient #2 was kept in line-of-sight observation per nursing judgement pending physician order resulting in a fall.

b) Failing to room psychiatric patients in licensed rooms during the night shift as evidenced by all patients identified as line-of-sight or high risk for falls requiring increased observation status being placed in the psych unit hallway due to lack of staff per interviews with the Director of Nursing, Unit Director, Psychiatric Nurse, and Mental Health Technician.

c) Failing to ensure restraints were not used for staff convenience and without physician order by restraining patient #5 and #2 for staff convenience per a physician order and patient #5 without a physician's order by raising all four side rails.

2) Ensure that each patient who fell received a comprehensive assessment.

a) Failing to identify the extent and location of injuries for patient #4 and #5 resulting in patient #4 not receiving a CT of her head until after her second fall striking her head and patient #5 not receiving an x-ray of her left hip after her second fall and the nurse's identified bruising and pain to the left hip.

b) failure to initiate/update the care plan and implement interventions to prevent falls and/or subsequent falls as evidenced by patient #5 falling 3 times and patient #4 falling twice.

3) The QA program fails to identify all falls, collect accurate fall data, trend for commonalities and/or contributing factors, and implement corrective action. The hospital staff failed to complete incident reports as per facility policy for 2 out of 6 identified falls (the second falls of patients #5 and #4).

The hospital submitted an acceptable Plan of Removal for the Immediate Jeopardy on 04/19/10 at 11:10 a.m. Present were S1Administrator; S2DON; S4RN, Asst. Admin. Operations; and S5RN. The Plan of Removal included:

1. Ensure that hospital staffing meets the needs of the patients as identified as high risk for falls and/or needing increased observation status.

a) All orders for one-to-one observation will be followed immediately. We will also contract with agencies to provide qualified staff if needed to comply with one-to-one orders. Timeline: Contract executed on 04/16/10. Responsible person: (name)

b) Plan 24 hours in advance for one-to-one needs. Nurse will immediately notify house supervisor when order for one-to-one is noted so that planning can begin. Educate all nursing staff and supervisors. Educators and Department directors are responsible for assuring this education is complete. Evidence of education compliance will be documented on education signature forms. Timeline: Education will begin immediately for all relevant staff as staff report to work until 100% of the designated staff have completed education. Responsible person: (S2DON)

d) Patients on Unit 54 will immediately be placed back in rooms at night and assessments and interventions will be completed per fall policy. Standard q 15 minute checks will continue per standard of care. Director/House Supervisor will be responsible for assessing staffing by shift taking into consideration census and patient acuity. Any staffing changes based upon acuity will be documented on the house supervisor report. Timeline: 04/16/10 Responsible Person: (S7RN, Unit 54 Director)

e) Educate nurses about appropriate use of restraints in accordance with policy. Example: restraints are never to be used in lieu of one-to-one monitoring for staff convenience. Charge nurse will assess each patient prior to restraint use and assure that all alternatives have been attempted. Educate all staff in direct patient care roles about the appropriate use of all 4 side rails. Any restrained patient will be reported to the house supervisor. Educators and Department directors are assuring this education is complete. Evidence of education compliance will be documented on education signature forms. Timeline: Education will begin immediately for all relevant staff as staff report to work until 100% of the designated staff have completed education. Responsible Person: (S2DON and S4RN, Asst. Admin Ops)

2) Ensure that each patient who falls receives a comprehensive assessment.

a) Educate all nursing staff about assessment activities required after a fall according to the falls protocol. Educators and Department directors are responsible for assuring this education is complete. Evidence of education compliance will be documented on education signature forms. Timeline: Education will begin immediately for all relevant staff as staff report to work until 100% of the designated staff have completed education. Responsible Person: (S2DON)

b) After completion of Code White and variance form, the Code White Team will identify and assure documentation of any new/additional interventions to prevent any further falls. The Code White form will be revised to reflect these additional activities. Educate all nursing staff. Educators and Department directors are responsible for assuring this education is complete. Evidence of education compliance will be documented on education signature forms. Timeline: Education will begin immediately for all relevant staff as staff report to work until 100% of the designated staff have completed education. Responsible Person: (S2DON)

3. The QA program fails to identify all falls, collect accurate data, trend for commonalities and/or contributing factors, and implement corrective action.

a) The Unit Director and Risk Manager will complete an intense assessment after each fall, including review of the medical record, Code White sheet, and variance report by the next business day and forwarded to the Slips/Falls committee. Timeline: Implement immediately. Responsible Person: (S2DON and S11RN, Risk Mgmt/QA.)

The Immediate Jeopardy was removed after the surveyor confirmed that the hospital implemented the above plan, but non-compliance remained at the condition level.

Based on record review of the Amended and Restated By-Laws of the hospital, the hospital's governing body failed to delegate the responsibility for the effective operation of the grievance process in writing to the grievance committee. Findings:

Review of the entire Amended and Restated By-Laws of the hospital revealed no documented evidence that the hospital's Governing Board delegated the responsibility for the effective operation of the Grievance process in writing to a Grievance Committee.

Based on record reviews and interviews the hospital failed to follow hospital policy and procedure for girevances as evidenced by: 1) failing to investigate a grievance alleging a physician order not to allow anesthesia administration to a patient during a surgical procedure (Patient #3) and 2) failing to send an initial letter to the patient and/or representative acknowledging receipt of the grievance or a timely response which included the name of the contact person, steps taken to investigate the grievance, the result of the grievance process, and the date of completion (Patient #5) for 2 of 2 focused sampled patients reviewed that had alleged grievances (Patient #3, Patient #5). Findings:

1) failing to investigate a grievance alleging a physician order not to allow anesthesia administration to a patient during a surgical procedure

Review of the Problem Resolution Report presented as the current Grievance Log for patient #3 read, "Patient #3's family member presented to administration on 3/24/10 at 2:00 p.m. to complain about S39MD." "...Patient #3 was admitted into the hospital on 2/20/10 then released to the family member. Patient #3 was readmitted on 3/5/10 to Unit 54 for confusion. While on Unit 54, Patient #3 broke her leg and was rushed to ICU (Intensive Care Unit). When taken to surgery on her leg, S39MD would not let them use anesthesia because he (S39) thought she was an addict. She (#3) was moved to Unit 42 for rehab (rehabilitation). She is still confused and having delusions. Family wants to release her to a nursing home (named)...S39MD is refusing to sign off on #3's release. Family and S38MD had a conflict last night on Unit 42 and S39MD threatened to call authorities on them. (Nursing Home named) is coming today to assess patient (#3). S39MD is claiming she (#3) is an addict and that's why she's having delusions. S41MD says she (#3) hasn't had meds (medications) in a month so is clear. They are complaining about attitude of S39MD and his intentional blocking of patient (#3) being released to nursing home... A 24 hour follow-up phone call was made by S3VPMA on 3/24/10...Assigned to S11RN, Risk Management, QA, and S6Service Guarantee Coordinator (with no date the staff were assigned the grievance and/or when the grievance was completed by the staff)... (This grievance was)...assigned and completed by S3VPMA on 3/24/10(-the same day)...Investigation: S39MD is not attending, only attendant who has signed off. S41MD & (and) S42MD is in charge. I spoke with (family member named) and S39MD. S3VPMA...ACTION: I spoke with (family member named) as well as S39MD. Situation is resolved. S39MD has signed off of case. Disposition per S41MD & (and) S42MD S3VPMA (typed name and date) 3/24/10 (with the) follow-up (section left blank)...".

In an interview with S3VPMA on 4/15/10 at 11:10 a.m., he indicated he had followed-up with S39MD on the allegations on the grievance from Patient #3. He reported S39MD does not dictate what medications anesthesia administers to a patient during a surgical procedure. He indicated he did not have any documentation of the investigation implemented with the allegations in the grievance on S39MD for Patient #3.

An interview was held with S2DON on 4/15/10 at 11:40 a.m.. She indicated there was no investigation on S39MD documented for Patient #3. She further indicated there was no follow-up done as per the grievance policy and procedure.

Review of a hospital policy titled " Customer Assistance/Grievance " , policy number RI-A-180, issued 03/03/00, last revised 03/08, presented as current hospital policy, reads in part: " I. Policy ....The hospital ' s Board of Directors is responsible for the effective operation of the grievance process. The Board delegates responsibility for reviewing and responding to patient complaints/grievances to the Grievance Committee. ....Quality of Care, ....Abuse or neglect. B. Grievance Process. 6. An initial letter will be sent to the patient and/or representative acknowledging receipt of the grievance by the Service Guarantee Coordinator ...8. The Complainant will receive a written notice of the committee ' s review. Every effort will be made for review and response within 14 days, but no longer than 30 days. 9. The written response will include the name of the contact person, steps taken to investigate the grievance, the result of the grievance process, and the date of completion.

2) failing to send an initial letter to the patient and/or representative acknowledging receipt of the grievance or a timely response which included the name of the contact person, steps taken to investigate the grievance, the result of the grievance process, and the date of completion

Review of the "Problem Resolution for Complaints/Grievances Form" for patient #5 dated 03/23/10 taken by S6, Service Quality Coordinator, revealed.... "Issue: Mrs. (complainant) called. She is very upset because her mother is a fall risk and she continues to fall. She is suppose to have a sitter so why is she falling. She was also suppose to have therapy which has not happened. She states her mother has bruises all over her and she feels this is abuse because we are not caring for her appropriately. She was in 4304 but supposedly last night they moved her closer to the station. She is very upset and wants someone to take care of this and call her back or talk to her sister who is suppose to be up there sometime this morning." Further review revealed..... "Describe the steps taken on behalf of the patient to investigate this Grievance: I spoke to (both daughters of patient #5) she was concerned about her mother falling three times and the bruises on her hand and hip. She was also concerned about a tear on her buttocks that she did not have before. She stated that her mother sit up too long yesterday and they did not make her bed until later that evening. Patient #5's daughter also stated that PT (Physical Therapy) was supposed to work with her; however that has not happened. She feels that she (patient #5) was neglected. She did not know if her mother was going to be moved closer to the nursing station. Under the section titled "Action Taken" on the same document revealed....."The patient does have a tear on her buttocks that was dressed with a Duoderm and cream applied to help heal area. (there is no ocumentation of notification of the physician or any physician order/progress note addressing the skin tear) I explained this to the daughter (name of daughter). The patient was not put on the protocol but will be placed on one. The patient was moved yesterday evening to 4322 across from the nurse's station. She also has a 1:1 sitter. I did speak with (patient #5's daughter) that if we have a difficult time arranging a sitter for tonight we may need a family member to stay with her. She agreed to this and stated that we just need to let her know. The patient does have a few bruises from the fall but is not in pain at this time. Physical Therapy attempted to work with the patient on yesterday but she would not corporate (sp?). The therapist planned to try to work with her again this evening ". Under the section titled "Please explain the outcome of this proceeding" revealed.... " Pt. #5's daughter was pleased with the plan. Pt. #5's other daughter was appreciative that I called her to resolve the problems. I will follow up again with the family on Wednesday to be sure everything continues to fall into place". The date of completion was documented as 03/23/10.

In a face to face interview on 04/14/10 at 2:00pm with S2DON and S8RN, Unit 43 Director both agreed that this was a Grievance and a Risk Management issue.

In a face to face interview on 04/14/10 at 2:15 p.m. in the presence of S2DON; S8RN, Unit 43 Director, S6, Service Quality Coordinator, indicated the representatives for patient #5 had not been sent a letter indicating the hospital was in receipt of the Grievance dated 03/23/10 because the grievance had been completely handled "in house". At 2:20 p.m. S11RN, Risk Management/QA entered the interview and indicated she looks at the " Action Taken" section of the Grievance and decides how it is going to be handled. She further indicated that a written response is "only required if the patient is gone". S11RN went on to indicate this was a complaint, not a grievance and required no written response. In the same interview S2 DON when asked if the hospital considered this to be a complaint or grievance responded that this was a Grievance and needed to be handled as such.

Review of policy #RI-A-180 titled "Customer Assistance/Grievance" last revised 03/08 and submitted by the hospital as the one currently in use revealed.... "B. Grievance 6. An initial letter will be sent to the patient and/or representative acknowledging receipt of the grievance by the Service Guarantee Coordinator...8. The Complainant will receive a written notice of the committee ' s review. Every effort will be made for review and response within 14 days, but no longer than 30 days. 9. The written response will include the name of the contact person, steps taken to investigate the grievance, the result of the grievance process, and the date of completion.

Based on interviews, the hospital failed to ensure personal privacy and dignity were respected for all patients admitted to Unit 54 as evidenced by moving all beds of those patients requiring LOS (Line of Sight), 1:1 observation and/or High Fall Risk (HRF) management into the hallway during the night shift in order to maintain visual contact for 21 of 21 patients on Unit 54. Findings:

In a face to face interview on 04/15/10 at 9:10am - 9:45am (in the presence of S7 Director of Unit 54 and S5 Quality Director) MHT S32, assigned to Unit 54 indicated the staff puts all patients on Unit 54 who require LOS, 1:1 observation and/or High Risk Fall Patients in the hall (which contains no curtains or partitions) in their beds at night to sleep so staff would be able to see the patients.

In a face to face interview on 04/14/10 at 10:35am-10:40am S7 Director of Unit 54 indicated all patients on Unit 54 who require LOS, 1:1 observation and/or High Risk Fall Patients are put in their beds in the hallway at night for safety issues. S7 further indicated all patients on Unit 54 are High Fall Risk Patients requiring close monitoring and denied the reason for placing the beds in the hallway was due to a staffing issue. Further she indicated she (S7) did not feel putting the patients in the hallway was a privacy or dignity issue.

During this same interview at 10:40 a.m., S2DON entered the room where the interview was being conducted with S7 Director ofnit 54 and S5 QUality Director. S2 DON (Director of Nursing) indicated all patients on the psyc unit (Unit 54) were put in their beds in the hallway for safety issues also felt this practice was not a dignity/privacy issue. S2 further denied there was a lack of staff to provide the patients with LOS, 1:1 and/or High Fall Risk Patients.

In an interview on 4/16/10 at 10:00 a.m., with S34LPN, Unit 54 indicated all patients on Unit 54 are High Fall Risk Patients.

In a face to face interview on 4/16/10 at 10:00 a.m., with S35RN, Unit 54 indicated all patients on Unit 54 are High Fall Risk Patients.

Based on observation, record review and interview the hospital failed to maintain a safe environment for each patient by: Findings:

1) failing to identify patients at high risk for falls by failing to accurately assess 1 of 5 patients with a recent history of a fall (#5) which resulted in the patient not being identified as a High Risk for Falls and sustaining a fall on the day of admission.

2) failing to identify patient behaviors placing them at high risk for injury by failing to follow hospital policy to implement care plan changes and monitor the effectiveness of those interventions by having a patient who had already fallen once in the hospital found by multiple staff members attempting to climb over the 4 raised side rails multiple times without taking immediate, effective corrective action to prevent the patient from harming herself and falling again for 1 of 5 sampled patients. (#5)

3) failing to notify the physician responsible for the care of a patient of a fall and failing to accurately document the events of a patients fall when the patient struck her head. (#4)

4) failing to fill out incident reports required by hospital policy to accurately identify adverse patient events for 2 of 5 patients (#4, #5).

5) failing to provide 1:1 direct patient observation for patient safety as ordered by the physician resulting in a fall for patient #5 who climbed over the side rails in the absence of the 1:1 supervision resulting in injury.

6) failing to follow hospital policy by not placing an indicator outside the patients room as stipulated in the "Christus Health Clinical Policy: Falls Protocol" for 9 of 11 randomly sampled patients identified as a high fall risk in a total census of 28 on unit 43 in 04/16/10 at 9:40 a.m.

7) failing to follow "Christus Health Clinical Policy: Falls Protocol" by placing a yellow arm band on patients identified as a high fall risk for 5 of 10 randomly sampled patients identified as a high fall risk and present on the floor (one patient was off the floor for tests) in a total census of 28 on Unit 43 on 04/16/10 at 9:40 a.m.

8) failing to follow the "Christus Health Clinical Policy: Falls Protocol" by failing to place an indicator on the medical record that the patient was at high risk for falls for 11 of 11 randomly sampled high fall risk patients in a total census of 28 on Unit 43 on 04/16/10 at 9:40 a.m.


1)

Review of the nursing notes for 03/18/10 at 1745 (5:45) for patient #5 revealed an admission assessment by S12RN. Review of the assessment revealed the following documentation: " Skin warm and dry. ...no evidence of rashes, lesions or skin breakdown. Ambulation ability - assistive device. Weight bearing ability - Full. Gait pattern - Shuffling. History of falls - No. " The fall risk score for patient #5 was 20. (Fall risk score of 0 - 24 is defined as low risk - basic interventions. 25 - 44 is Moderate risk - standard interventions. and > 44 is High risk - High Risk interventions)

In an interview on 04/14/10 at 9:10 a.m. S12RN confirmed that if she had added the recent history of a fall that this would have raised the Fall Risk Score of patient #5 to 45, in the High Risk for Fall range.

2)

Review of the nursing notes for patient #5 dated/timed 03/18/10 at 1745 (5:45) revealed an admission assessment by S12RN. Review of the assessment revealed the following documentation: " Skin warm and dry. ...no evidence of rashes, lesions or skin breakdown. Ambulation ability - assistive device. Weight bearing ability - Full. Gait pattern - Shuffling. History of falls - No. " The fall risk score for patient #5 was 20. (Fall risk score of 0 - 24 is defined as low risk - basic interventions. 25 - 44 is Moderate risk - standard interventions. and > 44 is High risk - High Risk interventions)

In an interview on 04/14/10 at 9:10 a.m. S12RN confirmed that if she had added the recent history of a fall that this would have raised the Fall Risk Score of patient #5 to 45, in the High Risk for Fall range.

In the same interview S12RN confirmed that her 03/18/10 at 1800 (6:00 p.m.) documentation of " Side Rails - Upper Times Two - Lower Times Two " is restraints and she had no physician order for restraints.

Review of the nursing documentation for 03/18/10 night shift by S14RN revealed the following: " 03/18/10 at 1949 (7:49 p.m.) Ambulation ability - Assistive device. Weight Bearing ability - full. Gait pattern - shuffling. Skin Location Modifier: Left. Skin Location Body Site: Knee. Skin Problem: SWELLING. History of Falls - Yes. Fall Risk Screening Score - 45 (high risk).

Further review of nursing documentation for 03/18/10 at 2040 (8:40 p.m.) read: " Patient was found sitting on floor " I need to get up and go. " Also " You don ' t look like my family. " Reoriented. Helped back into bed. Dr. and daughter notified per Code White Form. No distress noted. Verbally reoriented by house supervisor and nursing staff. However difficult due to patient hard of hearing with some possible short term memory loss. Will continue to monitor. " Documentation for 03/18/10 at 2045 (8:45 p.m.) under " Perform Neuro Check " reads: " S/P (status post) Fall - assessment done. No change in neurological status post fall. Very hard of hearing. "

In an interview on 04/15/10 at 8:20 a.m. with S27RN, Charge Nurse, she confirmed that 4 side rails were up and that this is considered restraints. She further stated that by putting 4 side rails up it makes the patient fall from higher. S27RN confirmed there were no changes made to the care plan of patient #5. S27RN also confirmed there was no documented head to toe assessment documented after the fall of patient #5.

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/18/10 at 2045 (8:45 p.m.) ....found on floor with all 4 rails up - trying to go to bathroom ....to void (has foley). " There is no changes documented in the plan of care of #5 after each fall or after she is repeatedly found attempting to go over the side rails.

There is no documentation of " customized fall prevention interventions " per the Christus Health Clinical Policy: Falls Protocol. There is no documentation that the Registered Nurse implemented and over saw individualized patient fall prevention, determined the factors influencing the risk and established an appropriate plan of care with interventions specific to the fall risk level.

The nurses failed to follow the Christus Health Clinical Policy: Falls Protocol by using side rails " because they are considered restraints and increase the possibility of patient entrapment. Additionally, full side rails can cause the patient to fall further if the patient attempts to climb over the rails. "

Further review of the medical record of patient #5 revealed there was no documentation of nursing instituting one-to one nursing for a patient with a recent fall and at risk for another fall, requesting the family stay with the patient, the patient being moved closer to the nursing station, scheduled toileting, increased frequency of staffing rounds, reduced patient load for primary nurse, team nursing approach (nurses taking turns charting in the patient at high risk for falls room), a head to toe assessment after the fall, documentation of interventions and monitoring of the effectiveness of the interventions. There was no documentation the patient/family viewed the " fall risk video " or was given the handout " A Guide to preventing Falls " per hospital policy. There is no documentation of notification of the physician of patient #5 having deterioration of her altered mobility status or persistent behaviors of climbing over the rails of the bed.

Review of the next nursing documentation for 03/18/10 at 2215 by S14RN revealed the following under Rounding comment - " Patient was found by Charge Nurse attempting to crawl over foot of bed. Repositioned back into bed. New bed with alarm found and replaced for patient. Will have nursing closely observe patient at bedside. "

Review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/19/10 at 1600 (4:00 p.m.) under Rounding Comment that read: " Found with legs over side rails attempting to get out of bed. Encouraged to remain in bed. No signs distress noted. Monitoring. " Further review of the " Shift Physical Assessment " dated/timed 03/19/10 at 2000 (8:00 p.m.) revealed: " Left Knee Swelling. Side Rails up - Upper Times Two - Lower Times Two. " Review of the " Nursing Rounds " dated/timed 03/19/10 at 2000 (8:00 p.m.) revealed: " Side Rails up - Upper Times Two - Lower Times One. " The Fall Risk Score is documented as 45 (high risk) on 03/19/10 at 2000 (8:00 p.m.)

Further review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/20/10 at 0000 (midnight) under Rounding Comment that read: " Found with legs over side rails attempting to get out of bed. Repositioned and pulled up in bed. Encouraged to remain in bed. No signs distress noted. Monitoring. "

Further review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/20/10 at 0315 (3:15 a.m.) under Rounding Comment that read: " Found on floor. States " I was trying to go to the bathroom. Code White protocol initiated. Physician and family notified. No signs of distress noted. 1:1 order noted. Sitter at bedside monitoring. "

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/18/10 at 2045 (8:45 p.m.) ....found on floor with all 4 rails up - trying to go to bathroom ....to void (has foley). " There is no changes documented in the plan of care of #5 after each fall or after she is repeatedly found attempting to go over the side rails.

There is no documentation of " customized fall prevention interventions " per the Christus Health Clinical Policy: Falls Protocol. There is no documentation that the Registered Nurse implemented and over saw individualized patient fall prevention, determined the factors influencing the risk and established an appropriate plan of care with interventions specific to the fall risk level.

Review of the "Christus Health Clinical Policy: Falls Protocol" revealed nurses should not raise 4 side rails " because they are considered restraints and increase the possibility of patient entrapment. Additionally, full side rails can cause the patient to fall further if the patient attempts to climb over the rails. "

Further review of the medical record of patient #5 revealed there was no documentation of nursing instituting one-to-one nursing for a patient with a recent fall and at risk for another fall, requesting the family stay with the patient, the patient being moved closer to the nursing station, scheduled toileting, increased frequency of staffing rounds, reduced patient load for primary nurse, team nursing approach (nurses taking turns charting in the patient at high risk for falls room), a head to toe assessment after the fall, documentation of interventions and monitoring of the effectiveness of the interventions. There was no documentation the patient/family viewed the " fall risk video " or was given the handout " A Guide to preventing Falls " per hospital policy. There is no documentation of notification of the physician of patient #5 having deterioration of her altered mobility status or persistent behaviors of climbing over the rails of the bed.

Review of the physician ' s Progress Note documented for 03/20/10 by S28MD, Attending Physician, revealed " fell again 3X (times) she advises -> has 1:1 now. x-ray of hip negative. " There is no documentation that the physician responsible for the care of patient #5 was notified of the L Hip pain of patient #5. (and that the x-ray was done on the R hip)

Review of the nursing documentation for 03/20/10 day shift by S16LPN dated/timed 03/20/10 at 0800 (8:00 a.m.) revealed the following " Left Knee Swelling and Left Hip Bruise. left hip and left knee tender to touch s/p fall. " There is no documentation of notification of the physician responsible for the care of patient #5 of the new assessment findings on the Left Hip. Under " Additional Pain Information " S16LPN documented " no complaints of pain, hurts when left knee or left hip is touched. "

In an interview on 04/14/10 at 8:50 a.m. with S23RN she stated she moved patient #5 from room 4306 to room 4322 on the evening shift on 03/22/10. She further indicated the move took 5 minutes. S23RN stated she told the family if they left the room to leave the door open and leave light on. S23RN further indicated that patient #5 was found on the floor during shift change. S23RN stated she was aware of the physician ' s order for 1:1 observation for patient #5 and that the physician was not notified the order was not being followed.

Review of the nursing documentation for 03/22/10 night shift by S22LPN at 1900 (7:00 p.m.) revealed the following: " left knee swelling, left hip bruise, left hip and knee tender to touch s/p fall. "

Documentation by S22LPN for 03/22/10 at 1900 (7:00 p.m.) also included the following: " Dr. is on the floor at the time of the Code White and ordered the vest restraints on the pt. This is her 5th time falling in this hospital. 1:1 is ordered by (name). House Supervisor states that they don ' t have the staffing to cover a 1:1. " Documentation for the same date/time by S22LPN under " Medical/Surgical Healing Restraints - Alternative Strategies Attempted " include " Family/Sitter at bedside. " Under " Demonstrated Patient Behavior " S22LPN documented " Climbing Out of Bed/Chair. "

Review of preprinted " Physician Orders Restraints " dated/timed 03/22/10 at 2000 (8:00 p.m.) revealed the following: " 1. Patient is at risk for harm to self and alternatives to restraints exhausted. 2. Apply least restrictive device: Vest Restraint is checked and Left and Right Soft Wrist (restraints) are checked. 3. When patient is no longer at risk for harm to self/others, restraints may be removed early. " Handwritten under this order is " or if 1:1 is in room. " (as ordered by the physician on 03/20/10 at 3:45 a.m.) Further review revealed this was a verbal order taken by S27RN, House Supervisor from S13MD, the same physician who ordered 1:1 supervision for patient #5 on 03/20/10 at 3:45 a.m.

In an interview on 04/14/10 at 10:40 a.m. with S13MD he stated that the " patient (#5) fell due to the staff not following his order for 1:1 observation. " (dated 03/20/10)

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated that no one was in the room per the physician ' s order for 1:1 supervision on the night shift for 03/22/10. S22LPN stated she could not remember if she notified the physician that they were not in compliance with his order for 1:1 supervision of patient #5. S22LPN stated that not following the physician ' s order contributed to the fall of patient #5 on 03/22/10. The DON and Director of Unit 43 were present for this interview.

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/22/10 at 1930 (7:30 p.m.) ....found on floor ...Medical/nursing actions: back to bed, reoriented ...Staff present at time of fall: No ...Risk factors for fall: disorientation ....Siderails in use: 4. "

Review of a hospital policy titled " One to One Guidelines " , policy number NR-1-2-20, issued 07/23/08, last revised 09/24/08, presented as current hospital policy, reads in part: " Purpose: The use of one-to-one sitters has become a common alternative to the application of restraints and to provide a care environment of increased safety. One-to-One usage has been used for patients at risk for disrupting therapy and those at risk for falls without evidence of improved outcomes from alternative actions. NOTE: physical restraint will be used as a last resort for patient safety. Potential Reasons for One-to-One usage: ... ...Fall since admission with risk of another fall .....Standard of Care. The patient/care giver can expect the patient will be provided a safe care environment. Procedure/Process. A. One-to-One Use Decision-Making Process: 1. Patient exhibits ...fall risk, post fall. Nursing Staff institutes alternatives to one-to-one ....(C. Alternatives for ...fall risk: 1. Family asked to stay with patient. 2. Patient moved closer to nurses ' station. 3. Use of bed with bed alarm. 4. Clinical review of necessity of medical devices ...possibly discontinue device/line ....7. Pain management - comfort measures. 8. Address possible hunger .....10. Medication to reduce anxiety. 11. Increased frequency of staffing rounds. 12. Toileting schedule ... ...16. Patient load reduced for primary nurse of this patient- allows more time to be spent with this patient. 17. Team nursing approach - Staff taking turns charting in patients room. 18. Use of restraints. (Last resort)) ....2. Assessment of effectiveness of alternatives ...NO - RN completes one-to-one justification form. 3. RN contacts Nursing Director or House Supervisor and reviews ... ...approval? Yes - One-to-One used ....When a One -to _one order is written the nurse will collaborate with the physician to discuss other alternatives if indicated. If the physician does not feel comfortable with alternatives presented, the order for 1:1 will be followed.

Review of a hospital policy titled " Patient Falls Prevention " , policy number TX-A-480, issued 07/91, last revised 10/08, presented as current hospital policy, reads in part: " Standard of Care. The patient/caregiver can expect to have adequate precautions taken to prevent harm to patients at high risk for falls. Standard of Practice. The nursing staff will assess all patients, identify those who are high-risk for falls and implement precautions to prevent harm/injury. Procedure. I. The nurse will assess the patients at risk for falls: A. High-risk patient (includes but not limited to one or more of the following): over 70 years of age; confused and disoriented, hallucinations; altered mental status; recent history of falls; chronic disease; recent history of loss of consciousness, seizures; unsteady on feet, syncope; poor general health; sensory deficits; ...drugs (i.e., anti-hypertensive ...); ....decreased mobility. II. The nurse will assess the patient for fall risk on admission and daily during the hospital stay or more frequently if indicated by a change in patient status. Patients at high risk for falls will be identified by a neon yellow band to be placed on the same limb as the patient identification bracelet. III. The nursing staff will check a " high risk " patient every two hours and document nursing interventions in the ongoing assessment ...Safety Interventions. Keep call bell/light within patient ' s reach at all times and assure that the patient is able to use it ....Assist patient with transfers/ambulation as needed ....Keep night light on during evening/night hours. Patient/Family Instruction. 1. Provide " fall risk video " , " One step at a time, for patient and family to view (Channel 5 or educational VCR video) or handout, " A Guide to Preventing Falls, can also be provided. Reportable Conditions. 1. Report the following to patient ' s physician: a. All falls. b. Development/deterioration of altered mobility. c. Development/deterioration of mental status. (confusion, disorientation/hallucinations) d. Deterioration in level of consciousness (LOC). e. Change in behavior .....f. Sensory impairment. Documentation. 1. Record Fall Risk Assessment Score daily under the ongoing Review of Systems. 2. In the event a patient does fall: reassess the patient; Document in the medical record the facts as they pertain to the situation; Document the assessment of the condition of the patient following the fall and any actions taken as a result of the fall; Identify and document the reason for the fall; Complete an online patient notification in Meditech; Notify the Unit Manager or House Supervisor and Risk Management .....Notification. a. M.D. b. Family. c. Unit Manager/House Supervisor. d. Risk Management.

Review of a hospital policy titled " Restraint/Medical-Surgical " , policy number TX-A-350, issued (no date), approved date 05/01, last revised 10/09, presented as current policy reads in part: " ...The guidelines for the use of restraints will only be initiated to protect a patient from injury to him/herself.....Policy....We believe the patient has the right to be free from any form of restraint that is not clinically necessary. Only the least restrictive, safe and effective restraint should be applied and only after alternatives have been attempted. When indicated, non-physical interventions are the preferred method .....The nurse/qualified staff will apply restraints using the least restrictive device per physician order .....The use of restraints for the prevention of falls should not be considered a routine part of fall prevention .....Staffing levels and assignments will be set to minimize circumstances that give rise to restraint use and maximize safety when restraints are used. The decision to use a restraint is not driven by diagnosis or treatment setting, but by comprehensive individual patient assessment including a physical assessment to identify medical problems that may be causing behavior changes in the patient that concludes that for this patient at this time, the use of less intrusive measures poses a greater risk than the risk of using restraint or seclusion ..10. Bed siderails ....the risk of siderail use is weighed against the risk presented by the patient ' s behavior as ascertained through individual assessment. Note: The elevation of all four siderails is considered a restraint. II. Alternatives to the use of Restraint and Seclusion: Less restrictive interventions will be attempted prior to the initiation of restraint ....These alternatives will be documented on the 24 hour restraint/seclusion flowsheet. Strategies and alternatives to prevent restraint use at Christus St. Patrick Hospital may include but are not limited to: ....Companionship/Increased Time at Bedside may include family, friends, volunteers and available staff .....Offer Family option of Sitting with Patient .....Offer Family Option of Employing Sitter ....III. Physician Orders: ...At any time, restraints cannot be discontinued and the restarted under the same order as this constitutes a PRN order........B. All restraint orders and renewal orders shall include the following: Date and time of the order; Type of restraint; Clinical justification for the restraint; ....Verbal Orders will be dated, timed and countersigned by the physician/LIP within 24 hours....Application of Restraints/Safety. Restraints may be utilized by members of the Health Care Team who have demonstrated competence in restraint application .....Use the least restrictive device that will provide patient/staff safety ....Do not restrain an individual in a bed with unprotected split side rails ...IX. Documentation Summary .....Documentation will include the following: Clinical justification or purpose...Alternatives.....Observations, checks and care needs; ... "

Review of a hospital policy titled " Christus Health Clinical Policy: Falls Protocol " , policy number 3.030, developed March 2008, presented as current hospital policy reads in part: " I. Objective: To establish policy, assign responsibility and provide procedures for patients at risk for falls; to systematically assess fall risk factors; provide guidelines for fall and repeat fall preventive interventions; and outline procedures for documentation and communication procedures....II. Policy Statement: Christus Health will implement basic and universal fall precautions for all patients. Upon admission, transfer, change in status, and following a fall; patients should be screened for their risk for falls .....Moderate fall risk interventions to reduce the risk for falls will be instituted for each patient determined to be at moderate or high fall risk and additional customized interventions will be implemented for high fall risk patients. Each patient who falls will be appropriately managed and the fall will be investigated for possible environmental and patient-specific changes ....J. Injury. Disruption of structure or function of some part of the body as a result of an unplanned event (e.g. fractures with or without treatment, sprains, cuts, bruises, aggravation of pre-existing complaints such as back pain....3. Upon admission, transfer, change in status, and following a fall; patients should be screened for their risk for falls. 5. Adherence of the patient and family to fall prevention interventions will be assessed every shift and appropriate corrective actions will be taken ....7. Customized fall prevention interventions will be instituted for high fall risk patients who are identified to have risk factors that may be modified ....9. Each patient that falls will have details of the fall, their post fall assessment, and all interventions documented in the medical record. 10. The physician of the patient who falls will be notified of the patient ' s fall. Responsibilities....2. Nurse Executive: Allocates appropriate resources and establishes processes needed to support the implementation of the falls protocol in the facility. Oversees the policy implementation at the facility...4. Nurse Manager/Director: Assures implementation of the fall policy .....5. Registered Nurse: Implements and oversees individualized patient fall prevention care including: a. Screening patients for fall risk on admission, transfer, change in condition, or following a fall .....b. Determining patient ' s fall risk level and factors influencing risk ....Establish appropriate patient plan of care with interventions specific to fall risk level. C. Communicating the patient ' s fall risk by: i. Placing an indicator on the patient room such as a magnetic falling star, falling leaf, or yellow dot; ii. Placing an optional indicator, e.g. sticker on the patient chart; iii. Placing a " Fall Risk " yellow armband on the patient; ....v. Communicating on hand-off the patient ' s fall risk. d. Supervising the provision of safe care and implementation of fall prevention care; e. Evaluating the effectiveness of the fall interventions for each patient; f. Communicating to staff, providers, and individuals designated by the patient to receive information that a patient has fallen; g. Requesting the interdisciplinary treatment team to review and modify the fall prevention interventions as appropriate; h. Completing the post-fall assessment with the collaboration of the Fall Response Team. 6. Physicians/Providers: Identifies and implements medical interventions to reduce falls and fall-related injury risk. 12. Interdisciplinary Fall Response Team: Responds to falls and conducts a post fall assessment. Collects data regarding falls and fall related injuries. Recommends prevention strategies for patients based on fall data .... B. 4. Customized interventions for high fall risk patients in addition to the basic and universal fall precautions and the moderate fall risk interventions include: a. ii. Do not use full side rails prevention because they are considered restraints and increase the possibility of patient entrapment. Additionally, full side rails can cause the patient to fall further if the patient attempts to climb over the rails .....5. Post-Fall Management. A. Immediately following a fall initiate the post fall response and documentation ....C. Take the following actions in the event of a witnessed fall, in which the patient is known to have sustained no head trauma from the fall: 1. Immediate actions. a. Check for injuries ...D. In the event of an unwitnessed fall, or one in which the patient sustains head trauma, or which there is uncertainty about any head trauma: b. Use the same protocol outlined above. (C) c. In addition perform neurological checks every 15 minutes X4, every 30 minutes X2, every hour X4, and then every 4 hours for 24 hours. Alert the attending physician to any changes. E. Modify the plan of care as indicated to address any changes in care as a result of the fall.


3)

The medical record for Patient #4 was reviewed. #4 was admitted to Unit 54 on 3/2/10 with the admitting diagnosis of Bipolar. Further review revealed #4 had Altered memory/thinking, Oriented to self only, Bilateral weakness to all extremities, Staggering gait pattern, Required required total assistance with positioning/activity in chair, Chairfast-must be assisted into chair or wheelchair, Wheelchair bound with maximum assistance from 3/8/10 to 3/9/10. On 3/9/10 at 9:03 p.m. (2103), #4 was line of sight, total assistance with positioning/activity in chair and confused with disorganized thoughts. At 10:20 p.m. (2220), #4 was "Alert" and found sitting in room on floor (patient fell) after the tech (S32MHT, Unit 54 ) left the patient in the room to get linen. At (11:30 p.m.) 2300, #4 was "Drowsy"-one hour and about 40 minutes after she fell. There was no documented evidence in the record the physician (S28) was notified of #4's change in condition at 11:30 p.m.. On 3/11/10 at 12:00 a.m. (0000), "...Heard pt fall... same area struck yesterday (3/9/10 at 10:20 p.m.)...". At 12:25 a.m. (0025), #4 was "Awake" then "Drowsy" at 3:00 a.m. (0300)- about 3 hours after she fell and hit her head. There was no documented evidence the physician (S28) was notified of #4's change in condition from alert to drowsy from 12:25 a.m. to 3:00 a.m. by S33RN, Unit 54.

Further review of #4's medical record revealed #4 had a 95- Fall Risk Screening Score. For Scores of 45 and greater, all basic, standard, and high fall prevention interventions were to be implemented as follows:
...Bedside Table within reach,
....Call light within reach,
...Room well lit,
...Room free of clutter,
...Equipment wheels locked,
...Bed at lowest position,
...Medication Instruction,
...Bed wheels locked,
...Non-slip footwear,
...No floor length clothing.
...Yellow Arm Band Applied,
...Environmental Screen,
...Hourly rounds,
...Medication review,
...Assisted when walking,
...Mobility aid next to bed,
...Instruct OOB (out of bed) with assistance.

Review of the Incident Report recorded on Patient #4's event occurred on 3/9/10 at 9:55 p.m. (2155)--the Nurse Round notes documented for the same event were timed 10:20 p.m. (2220)-25 minutes later read, "...Pt (patient) was found on the floor up against the wall by the door in her room..." Patient #4 was confused prior to the fall. Further review revealed S37RNCN, Unit 54 recorded "...Heard a loud noise come from the patient's room...the patient was on the floor, sitting near the wall up against a wheelchair...Moved her to a closer vicinity of the nurses' station...". S7Director, Unit 54 documented "...Nurse (S37RNCN, Unit 54 named) notified me of incident. Stated MHT (S32, Unit 54) had rolled patient into room and left patient unattended and patient fell out of her wheelchair. MHT (S32) had no explanation of why he left patient unattended in her room when she clearly had a yellow band on and ws (was) not ambulatory, but very impulsive. Talked with MHT (S32) 1:1 and also informed Charge Nurse (S37) that a code white should have been called, she stated that once she seen the patient on the floor, her first instinct was to help the patient along with the other staff. Processed with her the proedure (procedure) of calling code white...".

There was no Incident Report written for Patient #4's fall on 3/11/10 at 12:00 a.m. (0000).

The Preliminary Radiology Report With Addendum written by S38Radiologist on 3/11/10 at 3:04:08 AM Central for Patient #4 read, "CT BRAIN/HEAD, FALL-HIT OCCIPITAL REGION OF HEAD. LAC (laceration) TO OCCIPITAL REGION...Addendum created by (S38Radiologist's name) on 3/11/2010 3:04:08 AM (S28MD's name) is to be notified by S33RN, (Unit 54), who received the report as of 2:58 a.m. Central. Initial report created on 3/11/2010 2:51:14 AM Clinical information: FALL-HIT OCCIPITAL REGION OF HEAD. LAC (laceration) TO OCCIPITAL REGION. No prior study is available for comparison. Swelling / hematoma in the high posterior scalp. Left frontal-temporal subdural fluid of about 18 HUs of up to 6 mm in width. Midline shift of 4 mm toward the right...".

During an interview with S7Director, Unit 54 and S2DON on 4/14/10 from 12:50 p.m. to 1:30 p.m.. Patient #4's medical record was reviewed by both S7 and S2. S7Direct

Based on record review and interview the hospital failed to ensure that patients were free from all forms of abuse (unreasonable confinement by restraining a patient with 1:1 observation orders due to inability to provide adequate staffing) and neglect (failing to provide goods and services necessary to avoid physical harm due to failure to provide adequate staffing) for 4 of 5 sampled patients (#5, #4, #3, #2) by: Findings:

1) failing to ensure that a patient (#5) with physician orders for 1:1 observation were followed continuously for a patient who fell, with injury, when the hospital failed to have in place the physician ordered 1:1 direct observation.

2) failing to have adequate staffing in place to ensure a patient (#4) was kept in LOS (line of sight) at all times.

3) failing to follow hospital policy titled "Assisting a Patient to Walk" by failing to physically assist a patient with ambulation (#3) resulting in the patient falling and fracturing her Right Tibia/Fibula.

4) failing to keep in place Nurse initiated 1:1 observation as the least restrictive, effective means to ensure patient safety by leaving patient #2 alone resulting in a fall less than 5 minutes after the nurse left the room to administer medication to another patient.

1)

Patient #5

Review of the Admission Orders for patient #5 revealed the patient was admitted on 03/18/10 to S28MD with a diagnosis of Altered Mental status and CVA (cerebrovascular accident - stroke). Further orders included: " Physical Therapy and Occupational Therapy: Evaluate and treat " and " Physical Therapy and Occupational Therapy: Evaluate and treat in 24 hours. " Further review of the physician admission orders under " Activity " revealed the physician gave no orders for the activity level of patient #5.

Further review of handwritten Physician Orders dated 03/18/10 at 1930 (7:30 p.m.) revealed: " ...5. Fall Precautions .... "

Review of the nursing notes for 03/18/10 at 1745 (5:45) revealed an admission assessment by S12RN.

Review of the assessment revealed the following documentation: " Skin warm and dry. ...no evidence of rashes, lesions or skin breakdown. Ambulation ability - assistive device. Weight bearing ability - Full. Gait pattern - Shuffling. History of falls - No. " The fall risk score for patient #5 was 20. (Fall risk score of 0 - 24 is defined as low risk - basic interventions. 25 - 44 is Moderate risk - standard interventions. and > 44 is High risk - High Risk interventions)

In an interview on 04/14/10 at 9:10 a.m. S12RN confirmed that if she had added the recent history of a fall that this would have raised the Fall Risk Score of patient #5 to 45, in the High Risk for Fall range. S12RN further indicated that 2 staff members attempted to stand patient #5 to move her from the ER stretcher to the bed in the room. S12RN indicated that even with a 2 person assist it was determined that patient #5 was too weak to perform the transfer. Patient #5 was seated back on the ER stretcher and moved to the hospital bed in the room by sliding her over.

In the same interview S12RN confirmed that her 03/18/10 at 1800 (6:00 p.m.) documentation of " Side Rails - Upper Times Two - Lower Times Two " is restraints and she had no physician order for restraints.

Review of the nursing documentation for 03/18/10 night shift by S14RN revealed the following: " 03/18/10 at 1949 (7:49 p.m.) Ambulation ability - Assistive device. Weight Bearing ability - full. Gait pattern - shuffling. Skin Location Modifier: Left. Skin Location Body Site: Knee. Skin Problem: SWELLING. History of Falls - Yes. Fall Risk Screening Score - 45 (high risk).

Further review of nursing documentation for 03/18/10 at 2040 (8:40 p.m.) read: " Patient was found sitting on floor " I need to get up and go. " Also " You don ' t look like my family. " Reoriented. Helped back into bed. Dr. and daughter notified per Code White Form. No distress noted. Verbally reoriented by house supervisor and nursing staff. However difficult due to patient hard of hearing with some possible short term memory loss. Will continue to monitor. " Documentation for 03/18/10 at 2045 (8:45 p.m.) under " Perform Neuro Check " reads: " S/P (status post) Fall - assessment done. No change in neurological status post fall. Very hard of hearing. "

Review of the Meditech Patient Notification (incident report) revealed that patient #5 was " found on floor in patients room. " Nature of injury is documented as " no injury noted. " Fall information is documented as " Fell from: bed. Condition prior to fall: confused. Side Rail Position: 4 up. Was Fall Assessment completed prior to Fall: Y (yes). Was Fall Assessment Completed after Fall: Y. " Documentation entered by S27RN Charge Nurse on 03/18/10 at 2147 (9:47 p.m.) reads as follows: " called to room by nurse (S26RN) patient on floor, states she was trying to go to the bathroom to urinate (has a foley). Reoriented and placed back in bed with 2 person assist. Vitals stable. "

Further review of the document revealed that on 04/12/10 at 8:29 a.m. (the 26th day since the fall of patient and the day of entry on the complaint) S8RN, Unit Director, entered the following: " Patient was a high risk for falls. (review of the admission assessment fall risk revealed patient #5 was documented as having a fall risk score of 20 which is low risk. The initial assessment failed to include the recent history of a fall which would have placed #5 in the high risk for falls category) Patient had soaks (socks) on. Patient was educated not to get out of bed, but was confused. Alone in the room. A Code White was called. "

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/18/10 at 2045 (8:45 p.m.) ....found on floor with all 4 rails up - trying to go to bathroom ....to void (has foley). " There are no changes documented in the plan of care of #5 after each fall or after she is repeatedly found attempting to go over the side rails.

In an interview on 04/15/10 at 8:20 a.m. with S27RN, Charge Nurse, she confirmed that 4 side rails were up and that this is considered restraints. She further stated that by putting 4 side rails up it makes the patient fall from higher. S27RN confirmed there were no changes made to the care plan of patient #5. S27RN also confirmed there was no documented head to toe assessment documented after the fall of patient #5.

In an interview on 04/14/10 at 2:00 p.m. S8RN, Unit 43 Director, stated that there was no thorough investigation done on the 03/18/10 fall (1st fall) of patient #5. The DON was present for this interview.

Review of the next nursing documentation for 03/18/10 at 2200 by S14RN revealed the following under Neuro Check Comment - " No change in Neurological status post fall. Still needs reorienting which is difficult due to being very hard of hearing. "

Review of the next nursing documentation for 03/18/10 at 2215 by S14RN revealed the following under Rounding comment - " Watching television. Reoriented. Instructed repeatedly to not get out of bed without help. "

Review of the next nursing documentation for 03/18/10 at 2215 by S14RN revealed the following under Rounding comment - " Patient was found by Charge Nurse attempting to crawl over foot of bed. Repositioned back into bed. New bed with alarm found and replaced for patient. Will have nursing closely observe patient at bedside. "

Review of the nursing documentation for 03/19/10 for 0000 (midnight), 0100 (1:00 a.m.), 0200 (2:00 a.m.), and 0300 (3:00 a.m.) all revealed " nurse observing from bedside. "

Review of the nursing documentation by S14RN for 03/19/10 at 0300 (3:00 a.m.) under Rounding comment reads: " Patient pulled out IV. (intravenous catheter) IV restarted per (S27RN, Charge Nurse). Patient repeatedly reoriented. " I still need to get up and go outside " . Will continue to monitor at bedside. "

Review of the nursing documentation by S14RN for 03/19/10 at 0400 (4:00 a.m.) under Rounding comment reads: " Patient (#5) moving off bed. Stopped by nurse at bedside. Continuing to reorient. "

Review of the nursing documentation by S14RN for 03/19/10 at 0500 (5:00 a.m.) under Rounding comment reads: " nursing staff still at bedside. "

S14RN failed to show up for his scheduled interview with the surveyor ' s on 04/15/10. The hospital was not able to reschedule S14RN for interview. The DON stated S14RN was scheduled the previous day to be in this a.m. but he was a no show. Review of the medical record for patient #5 revealed S14RN was the nurse on duty for 2 of 3 of patient #5 ' s falls.

Review of the Physical Therapist documentation for the day shift on 03/19/10 at 1100 (11:00 a.m.) by S19PT revealed the following: " Pt. is a 94 Y/O (year old) admitted after she couldn't ' t get up from a fall at home and was found on the floor by a family member. Prior Mobility Status Level - Independent. Prior Activity Level - ADL ' s. (activities of daily living) Prior Living Arrangements - Home Alone. Living Situation Comment - ..Pt. lives alone, daughter ' s check in daily to help with cleaning and cooking. Are you having pain now? Y (yes) Pt. c/o (complain of) L (left) Leg Pain. Nursing Informed of Pain? Y. Face - Occasional Grimace/Frown. Transfers to chair. Transfers from bed. Additional Functional Mobility Assistance Required - Moderate Assist. Assistive Devices - Rolling Walker, Gait Belt. Pt. T/Ferred (transferred) bed to chair with Mod (moderate) assist X2. (two therapist helping) Pt. c/o pain L LE (left lower extremity) with mobilization. Also when calf is squeezed. Nursing notified. Recommend D.C. (discharge) to NH (nursing home) with OT/PT. "

Review of the " Hospitalist Assessment Form " dated/timed 03/19/10 at 12:30 p.m. by S28MD revealed " Gait - non-ambulatory. PT eval still pending. There is no documentation by the physician responsible for the care of patient #5 that she was notified that patient #5 was found on the floor on 03/18/10 at 2040 (8:40 p.m.)

Review of the nursing documentation for 03/19/10 at 1418 (2:18 p.m.) by S40RN, revealed " very weak, unable to put full weight on legs and Left Knee Swelling. "

Review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/19/10 at 1600 (4:00 p.m.) under Rounding Comment that read: " Found with legs over side rails attempting to get out of bed. Encouraged to remain in bed. No signs distress noted. Monitoring. " Further review of the " Shift Physical Assessment " dated/timed 03/19/10 at 2000 (8:00 p.m.) revealed: " Left Knee Swelling. Side Rails up - Upper Times Two - Lower Times Two. " Review of the " Nursing Rounds " dated/timed 03/19/10 at 2000 (8:00 p.m.) revealed: " Side Rails up - Upper Times Two - Lower Times One. " The Fall Risk Score is documented as 45 (high risk) on 03/19/10 at 2000 (8:00 p.m.).

Further review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/20/10 at 0000 (midnight) under Rounding Comment that read: " Found with legs over side rails attempting to get out of bed. Repositioned and pulled up in bed. Encouraged to remain in bed. No signs distress noted. Monitoring. "

Further review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/20/10 at 0315 (3:15 a.m.) under Rounding Comment that read: " Found on floor. States " I was trying to go to the bathroom. Code White protocol initiated. Physician and family notified. No signs of distress noted. 1:1 order noted. Sitter at bedside monitoring. "

Review of the Meditech Patient Notification Log revealed there was no incident report filled out for the fall of patient #5 on 03/20/10 at 3:15 a.m.

Review of the Code White form used by the hospital revealed: " Date/Time of Fall: 03/20/10 at 0315 (3:15 a.m.) ...Patient response to event: confused. Staff present at time of fall: No. Risk factors for Fall: Previous fall, confused. Side rails in Use: 4. "

Review of physician orders dated/timed 03/20/10 at 0345 (3:45 a.m.) revealed a telephone order from S13MD documented by S14RN that read " 1:1 (one to one observation) and x-ray of L (left) knee and R (right) hip.

In an interview with S13MD, Hospitalist, he stated that the nurse had documented the wrong hip to be x-rayed. S13MD stated he ordered the Left hip to be x-rayed as he would expect blunt force from a fall onto the left knee to be projected to the left hip. S13MD could not explain why he authenticated the same order (without date or time) if it was not correct.

Review of the Fall Risk Assessment dated/timed 03/20/10 at 0338 (3:38 a.m.) revealed patient #5 now had a Fall Risk score of 75.

Review of the physician ' s Progress Note documented for 03/20/10 by S28MD, Attending Physician, revealed " fell again 3X (times) she advises -> has 1:1 now. x-ray of hip negative. " There is no documentation that the physician responsible for the care of patient #5 was notified of the L Hip pain of patient #5. (and that the x-ray was done on the R hip)

Review of the nursing documentation for 03/20/10 day shift by S16LPN dated/timed 03/20/10 at 0800 (8:00 a.m.) revealed the following " Left Knee Swelling and Left Hip Bruise. left hip and left knee tender to touch s/p fall. " There is no documentation of notification of the physician responsible for the care of patient #5 of the new assessment findings on the Left Hip. Under " Additional Pain Information " S16LPN documented " no complaints of pain, hurts when left knee or left hip is touched. "

In an interview on 04/12/10 at 2:00 p.m. with S16LPN he stated he could not remember if he was given the assessment findings of left hip bruise/pain in report. He further indicated that if it was a new finding he would notify the physician responsible for the care of the patient.

In an interview on 04/13/10 at 1:50 p.m. with the DON and S8RN, Unit 54 Director, both stated they would expect physician notification of the change in status/assessment of patient #5.

The DON further indicated in an interview on 04/13/10 at 3:00 p.m. that patient #5 was at risk to fall, that she was left alone in the room and that she fell as a result of this. Take out.

In an interview on 04/14/10 at 9:20 a.m. with the DON she confirmed that there was no variance/incident report filled out for this fall per hospital policy.

Review of the Fall Risk Assessment dated/timed 03/20/10 at 0800 (8:00 a.m.) revealed patient #5 had a Fall Risk Score of 95.

Review of the nursing documentation for 03/20/10 night shift by S14RN dated/timed 03/20/10 at 2000 (8:00 p.m.) revealed: " bilateral lower extremity push weakness, left knee swelling, left hip bruising. "

Review of the documentation by S14RN dated/timed 03/20/10 at 2000 (8:00 p.m.), 2200 (10:00 p.m.), 0000 (midnight), 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) under Nursing Rounds - Rounding Comment revealed: " Resting in bed. Family at bedside ... ... "

Review of the nursing documentation for 03/21/10 day shift by S15LPN dated/timed 03/21/10 at 0900 (9:00 a.m.) revealed patient #5 had a Fall Risk Score of 75. Review of the nursing documentation for 03/21/10 at 1000 (10:00 a.m.) by S15LPN revealed " Left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Further review of the nursing documentation for 03/21/10 at 1800 (6:00 p.m.) revealed " Bedbath given - Small skin tear noted on buttocks - placed on pillows. " There is no documentation of notification of the physician responsible for the care of patient #5 of the skin tear.."

Review of the physician ' s Progress Note dated 03/21/10 at 10:30 a.m. revealed " Fall - Secondary to generalized weakness. "

Review of the nursing documentation for 03/21/10 night shift by S14RN dated/timed 03/21/10 at 2000 (8:00 p.m.) revealed: " ...No evidence of Rashes, Lesions, or Skin Breakdown. Left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Review of the Fall Risk Assessment dated/timed 03/21/10 at 2000 (8:00 p.m.) revealed patient #5 had a Fall Risk Score of 95.

Review of the nursing documentation for 03/22/10 at 0000 (midnight), 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) revealed " sitter at bedside. "

Review of the PT documentation for 03/22/10 at 1105 (11:05 a.m.) revealed " treatment not performed " and the reason documented is " maintenance working in room. " Further review of the PT documentation for 03/22/10 at 1135 (11:35 a.m.) revealed " treatment not performed " and the reason documented is " Patient Declined. " There is no documentation of notification of the physician responsible for the care of patient #5 that PT was not done as ordered.

Review of physician orders written by S29MD dated/timed 03/22/10 at 1:00 p.m. revealed the physician again ordered " Fall Precautions. "


Review of the physician ' s Progress Note for 03/22/10 (no time indicated) by S13MD, Hospitalist, revealed " s/p fall. Exam: no focal neurological deficit. No evidence of trauma. Vest restraint. "

Review of the nursing documentation for 03/22/10 day shift by S23RN at 1600 (4:00 p.m.) revealed " family at chairside." Pt. sitting up in chair in room. Very confused and not talking clear. Will move Pt. closer to nurses ' station. "

Review of the nursing documentation for 03/22/10 day shift by S40RN revealed documentation timed at 1611 (4:11 p.m.) that read in part: " family at bedside. "

Review of nursing documentation on 03/22/10 at 1800 (6:00 p.m.) by S23RN revealed " move pt. to room 4322 for safety across from nurse ' s station for closer monitoring. "

In an interview on 04/14/10 at 8:50 a.m. with S23RN she stated she moved patient #5 from room 4306 to room 4322 on the evening shift on 03/22/10. She further indicated the move took 5 minutes. S23RN stated she told the family if they left the room to leave the door open and leave light on. S23RN further indicated that patient #5 was found on the floor during shift change. S23RN stated she was aware of the physician ' s order for 1:1 observation for patient #5 and that the physician was not notified the order was not being followed.

Review of the nursing documentation for 03/22/10 night shift by S22LPN at 1900 (7:00 p.m.) revealed the following: " left knee swelling, left hip bruise, left hip and knee tender to touch s/p fall. "

Documentation by S22LPN for 03/22/10 at 1900 (7:00 p.m.) also included the following: " Dr. is on the floor at the time of the Code White and ordered the vest restraints on the pt. This is her 5th time falling in this hospital. 1:1 is ordered by (name). House Supervisor states that they don ' t have the staffing to cover a 1:1. " Documentation for the same date/time by S22LPN under " Medical/Surgical Healing Restraints - Alternative Strategies Attempted " include " Family/Sitter at bedside. " Under " Demonstrated Patient Behavior " S22LPN documented " Climbing Out of Bed/Chair. "

Review of the Meditech Patient Notification Form (incident report) revealed an event date of 03/22/10 at 1930 (7:30 p.m.). Location is listed as room 4322. Nature of injury is " No Injury Noted. " Further review revealed the following documentation: " Fell from: bed. Condition prior to fall: confused. Side rail position: 4 up. Was Fall Assessment completed prior to fall? N (no). Was fall assessment completed after fall? Y. " The following documentation was entered by S27RN, Charge Nurse on 03/22/10 at 2000 (8:00 p.m.): " Patient found on floor by bed. States she was trying to go to bathroom. Put back in bed and reoriented. " S8RN, Unit 43 Director documented the following on 03/25/10 at 9:32 a.m.: " Patient was confused alone in room. (the physician had ordered 1:1 supervision on 03/20/10) Family and physician notified of fall. Code White called. Patient has slipper soaks (sp?) and yellow flag used. Patient moved closer to nurse station. (this move from room 4306 to 4322 occurred prior to the patient fall) Patient placed back on a 1:1. No narcotics given. "

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/22/10 at 1930 (7:30 p.m.) ....found on floor ...Medical/nursing actions: back to bed, reoriented ...Staff present at time of fall: No ...Risk factors for fall: disorientation ....Siderails in use: 4. "

Review of preprinted " Physician Orders Restraints " dated/timed 03/22/10 at 2000 (8:00 p.m.) revealed the following: " 1. Patient is at risk for harm to self and alternatives to restraints exhausted. 2. Apply least restrictive device: Vest Restraint is checked and Left and Right Soft Wrist (restraints) are checked. 3. When patient is no longer at risk for harm to self/others, restraints may be removed early. " Handwritten under this order is " or if 1:1 is in room. " (as ordered by the physician on 03/20/10 at 3:45 a.m.) Further review revealed this was a verbal order taken by S27RN, House Supervisor from S13MD, the same physician who ordered 1:1 supervision for patient #5 on 03/20/10 at 3:45 a.m.

In an interview on 04/14/10 at 10:40 a.m. with S13MD he stated that the " patient (#5) fell due to the staff not following his order for 1:1 observation. " (dated 03/20/10)

In an interview on 04/14/10 at 2:00 p.m. S8RN, Unit 43 Director was asked if there was an investigation into the fall of patient #5 on 03/22/10 (fall #3). She replied she was in the process of performing the investigation. She was asked to provide the documentation to the surveyor ' s. S8RN, Unit 43 Director produced a copy of the 2nd Grievance Report from the family of patient #5 with a few handwritten notes.

Review of the nursing documentation for 03/22/10 at 2200 (10:00 p.m.) by S22LPN under Rounding Comment reads: " Resting in bed. Alone in room. Restraints applied. Pt. has pulled out her IV. Wrist restraints applied. "

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated that no one was in the room per the physician ' s order for 1:1 supervision on the night shift for 03/22/10. S22LPN stated she could not remember if she notified the physician that they were not in compliance with his order for 1:1 supervision of patient #5. S22LPN stated that not following the physician ' s order contributed to the fall of patient #5 on 03/22/10. The DON and Director of Unit 43 were present for this interview.

Review of the physician ' s Progress Note dated 03/23/10 at 11:15 a.m. by S13MD, Hospitalist, revealed " pt fell last night. No injury.

Review of the nursing documentation for 03/23/10 day shift by S23RN dated/timed 03/23/10 at 0800 (8:00 a.m.) reads in part: " left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Further review of the documentation by S23RN for 03/23/10 at 0800 (8:00 a.m.) under Rounding Comments revealed: " Awake. Alert. Oriented to person, and confused. ... ...Bil. (bilateral) wrist restraints intact. Pt. pulls out all tubing and climbs out of bed per self and unable to walk. 1:1 supervision in room with pt. Daughter at bedside. Pt. pulling off 02 at this time. Nurse placed it back. "

Review of a PT note for 03/23/10 at 1330 (1:30 p.m.) by S21PTA revealed under daily note comment: " after removing wrist restraints and attempting to sit EOB (edge of bed) Pt became combative. Pt hitting and digging with fingernails. Unable to secure wrist restraints. Notified sitter and she will watch Pt until restraints can be reapplied. "

In an interview on 04/13/10 at 1:40 p.m. with the DON she confirmed that neither the PTA nor the sitter in the room with patient #5 had training to apply or remove restraints. This does not belong in this tag.

Review of the documentation by S23RN for 03/23/10 at 1530 (3:30 p.m.) under Nursing Rounds - Rounding Comment read: " assist to chair in bedroom. Daughter and 1:1 sitter at bedside. Wrist restraints off at this time. " Under Additional restraint Information documented on 03/23/10 at 1530 (3:30 p.m.) S23RN documented " Verbal contract with Pt. and Daughter to have Pt. sit in chair without restraints at this time. With also 1:1 sitter at bedside to monitor pulling of tubes and attempting to get up. "

Review of the nursing documentation for 03/23/10 night shift by S22LPN revealed documentation for 03/23/10 at 1900 (7:00 p.m.) that read in part: " left knee swelling, left hip bruise, resting in bed, 1:1 in room ... " Further review of the documentation by S22LPN on 03/23/10 at 2200 (10:00 p.m.), 0000 (midnight), 03/24/10 at 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) revealed 1:1 in room.

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated she could not remember if she notified the physician responsible for the care of patient #5 of the left hip bruise/pain. S22LPN further indicated that there was 1:1 supervision in the room of patient #5 on the night of 03/23/10 and that patient #5 had no falls that night. S22LPN further stated that 1:1 supervision was effective in keeping patient #5 from falling.

Review of the nursing documentation for 03/24/10 day shift by S24LPN dated/timed 03/24/10 at 0800 (8:00 a.m.) read in part: " left knee swelling, left hip bruise. "

Review of the Discharge Education for Patient documented on 03/24/10 at 0905 (9:05 a.m.) revealed under Additional Activity Limitation Instructions " Fall Precaution. " Patient #5 was discharged to NH " a " .

In an interview on 04/14/10 at 2:30 p.m. with S24LPN she confirmed her documentation of left hip bruised. S24LPN further indicated she did not remember the patient (#5) of if she notified the physician responsible for the care of the patient of the bruise.

Review of the Discharge Summary with a DD (date dictated) of 03/23/2010 (no time indicated) by S29MD revealed the following: " FINAL DIAGNOSES: 1. Altered mental status secondary to dementia....3. Rhabdomyolosis, resolved.......5. Hypertension, stable..... HOSPITAL COURSE: This is a 94 year old female with significant past history of hypertension. The patient was brought in by a family member due to altered mental status and a fall ... ...The patient is awake but oriented to people and place. The patient had overall weakness due to the age of 94. The patient otherwise was in a relatively stable condition. The patient had a fall last night but did not sustain any injury or fracture ....DISPOSITION: She (patient #5) will be discharged to Nursing Home tomorrow morning around 10 a.m. .....Activity will be as tolerated. Fall precautions. The patient needs close monitoring due to dementia ... "

Review of a hospital policy titled " One to One Guidelines " , policy number NR-1-2-20, issued 07/23/08, last revised 09/24/08, presented as current hospital policy, reads in part: " Purpose: The use of one-to-one sitters has become a common alternative to the application of restraints and to provide a care environment of increased safety. One-to-One usage has been used for patients at risk.....for falls without evidence of improved outcomes from alternative actions. NOTE: physical restraint will be used as a last resort for patient safety. Potential Reasons for One-to-One usage: ... ...Fall since admission with risk of another fall .....Standard of Care. The patient/care giver can expect the patient will be provided a safe care environment. Procedure/Process. A. One-to-One Use Decision-Making Process: 1. Patient exhibits ...fall risk, post fall. Nursing Staff institutes alternatives to one-to-one ....(C. Alternatives for ...fall risk: 1. Family asked to stay with patient. 2. Patient moved closer to nurses ' station. 3. Use of bed with bed alarm. 4. Clinical review of necessity of medical devices ...possibly discontinue device/line ....7. Pain management - comfort measures. 8. Address possible hunger .....10. Medication to reduce anxiety. 11. Increased frequency of staffing rounds. 12. Toileting schedule ... ...16. Patient load reduced for primary nurse of this patient- allows more time to be spent with this patient. 17. Team nursing approach - Staff taking turns charting in patients room. 18. Use of restraints. (Last resort)) ....2. Assessment of effectiveness of alternatives ...NO - RN completes one-to-one justification form. 3. RN contacts Nursing Director or House Supervisor and reviews ... ...approval? Yes - One-to-One used ....When a One -to _one order is written the nurse will collaborate with the physician to discuss other alternatives if indicated. If the physician does not feel comfortable with alternatives presented, the order for 1:1 will be followed.

Review of a hospital policy titled " Patient Falls Prevention " , policy number TX-A-480, issued 07/91, last revised 10/08, presented as current hospital policy, reads in part: " Standard of Care. The patient/caregiver can expect to have adequate precautions taken to prevent harm to patients at high risk for falls. Standard of Practice. The nursing staff will assess all patients, identify those who are high-risk for falls and implement precautions to prevent harm/injury. Procedure. I. The nurse will assess the patients at risk for falls: A. High-risk patient (includes but not limited to one or more of the following): over 70 years of age; confused and disoriented, hallucinations; altered mental status; recent history of falls; chronic disease; recent history of loss of consciousness, seizures; unsteady on feet, syncope; poor general health; sensory deficits; ...drugs (i.e., anti-hypertensive ...); ....decreased mobility. II. The nurse will assess the patient for fall risk on admission and daily during the hospital stay or more frequently if indicated by a change in patient status. Patients at high risk for falls will be identified by a neon yellow band to be placed on the same limb as the patient identification bracelet. III. The nursing staff will check a " high risk " patient every two hours and document nursing interventions in the ongoing assessment ...Safety Interventions. Keep call bell/light within patient ' s reach at all times and assure that the patient is able to use it ....Assist patient with transfers/ambulation as needed ....Keep night light on during evening/night hours. Patient/Family Instruction. 1. Provide " fall risk video " , " One step at a time, for patient and family to view (Channel 5 or educational VCR video) or handout, " A Guide to Preventing Falls, can also be provided. Reportable Conditions. 1. Report the following to patient ' s physician: a. All falls. b. Development/deterioration of altered mobility. c. Development/deterioration of mental status. (confusion, disorientation/hallucinations) d. Deterioration in level of consciousness (LOC). e. Change in behavior .....f. Sensory impairment. Documentation. 1. Record Fall Risk Assessment Score daily under the ongoing Review of Systems. 2. In the event a patient does fall: reassess the patient; Document in the medical record the facts as they pertain to the situation; Document the assessment of the condition of the patient following the fall and any actions taken as a result of the fall; Identify and document the reason for the fall; Complete an online patient notification in Meditech; Notify the Unit Manager or House Supervisor and Risk Management .....Notification. a. M.D. b. Family. c. Unit Manager/House Supervisor. d. Risk Management.

Review of a hospital policy titled " Restraint/Medical-Surgical " , policy number TX-A-350, issued (no date), approved date 05/01, last revised 10/09, presented as current policy reads in part: " General Statement. " The guidelines for the use of restraints will only be initiated to protect a patient from injury to him/herself or to others....Policy......We believe the patient has the right to be free from any form of restraint that is not clinically necessary. Only the least restrictive, safe and effective restraint should be applied and only after alternatives have been attempted. When indicated, non-physical interventions are the preferred method .....The nurse/qualified staff will apply restraints using the least restrictive device per physician order ....Christus St. Patrick Hospital recognizes that all patients have a right to considerate, respectful care at all times, with recognition of their personal safety, dignity, rights and well being. Restraints shall only be used for patient safety and will never be used for purposes of staff convenience or patient discipline ... ...Restraint use will not be based on a patient ' s restraint history or solely on th

Based on record review and interview the hospital failed to ensure physician orders had been followed for use of the least restrictive fall prevention methods as evidenced by a patient with an order for use of least restrictive methods for fall prevention were used by failing to ensure the 1:1 observation was in place continuously for patient #5 who fell three times during her hospitalization while "Fall Precaution's" were ordered and once while non-compliance with a physician ordered, proven effective method of patient safety was not in place. Findings:

Review of the nursing notes dated 03/18/10 at 1745 (5:45 p.m..) revealed an admission assessment by S12RN. The fall risk score for patient #5 was 20. (Fall risk score of 0 - 24 is defined as low risk - basic interventions. 25 - 44 is Moderate risk - standard interventions. and > 44 is High risk - High Risk interventions)

In an interview on 04/14/10 at 9:10 a.m. S12RN confirmed that if she had added the recent history of a fall that this would have raised the Fall Risk Score of patient #5 to 45, in the High Risk for Fall range.

Review of the medical record for patient #5 revealed that on the 03/18/10 patient #5 fell (fall #)1 at 2040 (8:40 p.m.).

Further review of the medical record revealed patient #5 was found by nursing staff attempting to climb over the side rails/foot board on 03/18/10 at 2300 (11:00 p.m.), 03/19/10 at 1600 (4:00 p.m.) and 03/20/10 at 0000 (midnight).

Review of the physician orders for patient #5 revealed that S13MD, Hospitalist, had ordered 1:1 observation status for patient #5 on 03/20/10 at 0345 (3:45 a.m.). (after fall #2)

Review of the nursing documentation for 03/20/10 night shift revealed the family stayed with the patient all night. Patient #5 did not fall on that shift.

Review of the medical record revealed that on the 03/21/10 the 1:1 direct observation was in place for patient #5. Patient #5 did not sustain a fall on that shift.

Review of the 03/22/10 day shift documentation revealed the 1:1 was in place. Patient #5 did not sustain a fall on the shift.

Further review of the medical record revealed that patient #5 fell on 03/22/10 at 1900 (7:00 p.m.) (fall #3) while the physician ordered 1:1 supervision was not in place.

Documentation by S22LPN for 03/22/10 at 1900 (7:00 p.m.) also included the following: " Dr. is on the floor at the time of the Code White and ordered the vest restraints on the pt. This is her 5th time falling in this hospital. 1:1 is ordered by (name). House Supervisor states that they don ' t have the staffing to cover a 1:1. " Documentation for the same date/time by S22LPN under " Medical/Surgical Healing Restraints - Alternative Strategies Attempted " include " Family/Sitter at bedside. " Under " Demonstrated Patient Behavior " S22LPN documented " Climbing Out of Bed/Chair. "

Review of preprinted " Physician Orders Restraints " dated/timed 03/22/10 at 2000 (8:00 p.m.) revealed the following: " 1. Patient is at risk for harm to self and alternatives to restraints exhausted. 2. Apply least restrictive device: Vest Restraint is checked and Left and Right Soft Wrist (restraints) are checked. 3. When patient is no longer at risk for harm to self/others, restraints may be removed early. " Handwritten under this order is " or if 1:1 is in room. " (as ordered by the physician on 03/20/10 at 3:45 a.m.) Further review revealed this was a verbal order taken by S27RN, House Supervisor from S13MD, the same physician who ordered 1:1 supervision for patient #5 on 03/20/10 at 3:45 a.m.

In an interview on 04/14/10 at 10:40 a.m. with S13MD he stated that the " patient (#5) fell due to the staff not following his order for 1:1 observation. " (dated 03/20/10)

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated that no one was in the room per the physician ' s order for 1:1 supervision on the night shift for 03/22/10. S22LPN stated she could not remember if she notified the physician that they were not in compliance with his order for 1:1 supervision of patient #5. S22LPN stated that not following the physician ' s order contributed to the fall of patient #5 on 03/22/10. The DON and Director of Unit 43 were present for this interview.

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/22/10 at 1930 (7:30 p.m.) ....found on floor ...Medical/nursing actions: back to bed, reoriented ...Staff present at time of fall: No ...Risk factors for fall: disorientation ....Siderails in use: 4. "

Review of the nursing documentation for 03/23/10 at 0600 (6:00 a.m.) revealed that patient #5 was restrained and "alone in the room." Further review of the restraint order issued and signed by S13MD revealed that "restraints may be removed early...if 1:1 is in room."

Review of the documentation for 03/23/10 for 0800 (8:00 a.m.) revealed the patient's daughter was in the room. Patient #5 did not fall on the day shift of 03/23/10 while direct observation was in place.

Review of the night shift documentation for 03/23/10 revealed 1:1 observation was in place all night and patient #5 did not sustain a fall.

Based on record review and interview the hospital failed to ensure that the use of restraints or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for 1 of 5 sampled patients restrained without a physician order (Patient #5). Findings:

Review of the Code White form used by the hospital to document incidents of falls for Patient #5 revealed the following: "Date/time of Fall: 03/18/10 at 2045 (8:45 p.m.) ....found on floor with all 4 rails up - trying to go to bathroom ....to void (has foley)."

In an interview on 04/14/10 at 9:10 a.m. S12RN confirmed that if she had added the recent history of a fall on the initial nursing assessment that this would have raised the Fall Risk Score of patient #5 to 45, in the High Risk for Fall range.

In the same interview S12RN confirmed that her 03/18/10 at 1800 (6:00 p.m.) documentation of " Side Rails - Upper Times Two - Lower Times Two " is restraints and she had no physician order for restraints.

In an interview on 04/15/10 at 8:20 a.m. with S27RN, Charge Nurse, she confirmed that 4 side rails were up and that this is considered restraints. She further stated that by putting 4 side rails up it makes the patient fall from higher.

Review of the Code White form for Patient #5 revealed: "Date/Time of Fall: 03/20/10 at 0315 (3:15 a.m.) ...Patient response to event: confused. Staff present at time of fall: No. Risk factors for Fall: Previous fall, confused. Side rails in Use: 4."

Review of the Code White form used by the hospital revealed: " Date/Time of Fall: 03/20/10 at 0315 (3:15 a.m.) ...Patient response to event: confused. Staff present at time of fall: No. Risk factors for Fall: Previous fall, confused. Side rails in Use: 4. "

Review of the physician ' s Progress Note documented for 03/20/10 by S28MD, Attending Physician, revealed " fell again 3X (times) she advises -> has 1:1 now. x-ray of hip negative. " There is no documentation that the physician responsible for the care of patient #5 was notified of the L Hip pain of patient #5. (and that the x-ray was done on the R hip)

The DON indicated in an interview on 04/13/10 at 3:00 p.m. that patient #5 was at risk to fall, that she was left alone in the room and that she fell as a result of this.

In an interview on 04/14/10 at 9:20 a.m. with the DON she confirmed that there was no variance/incident report filled out for this fall per hospital policy.

Review of the Code White for Patient #5 revealed the following: "Date/time of Fall: 03/22/10 at 1930 (7:30 p.m.) ....found on floor ...Medical/nursing actions: back to bed, reoriented ...Staff present at time of fall: No ...Risk factors for fall: disorientation ....Siderails in use: 4."

Review of preprinted " Physician Orders Restraints " dated/timed 03/22/10 at 2000 (8:00 p.m.) revealed the following: " 1. Patient is at risk for harm to self and alternatives to restraints exhausted. 2. Apply least restrictive device: Vest Restraint is checked and Left and Right Soft Wrist (restraints) are checked. 3. When patient is no longer at risk for harm to self/others, restraints may be removed early. " Handwritten under this order is " or if 1:1 is in room. " (as ordered by the physician on 03/20/10 at 3:45 a.m.) Further review revealed this was a verbal order taken by S27RN, House Supervisor from S13MD, the same physician who ordered 1:1 supervision for patient #5 on 03/20/10 at 3:45 a.m.

In an interview on 04/14/10 at 10:40 a.m. with S13MD he stated that the " patient (#5) fell due to the staff not following his order for 1:1 observation. " (dated 03/20/10)

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated that no one was in the room per the physician ' s order for 1:1 supervision on the night shift for 03/22/10. S22LPN stated she could not remember if she notified the physician that they were not in compliance with his order for 1:1 supervision of patient #5. S22LPN stated that not following the physician ' s order contributed to the fall of patient #5 on 03/22/10. The DON and Director of Unit 43 were present for this interview.

Review of the physician's orders for patient #5 revealed no documented evidence the use of side rails X four had been ordered.

The nurses failed to follow the "Christus Health Clinical Policy: Falls Protocol" by using side rails " because they are considered restraints and increase the possibility of patient entrapment. Additionally, full side rails can cause the patient to fall further if the patient attempts to climb over the rails. "

Review of a hospital policy titled " Christus Health Clinical Policy: Falls Protocol " , policy number 3.030, developed March 2008, presented as current hospital policy reads in part: "B. 4. Customized interventions for high fall risk patients in addition to the basic and universal fall precautions and the moderate fall risk interventions include: a. ii. Do not use full side rails prevention because they are considered restraints and increase the possibility of patient entrapment. Additionally, full side rails can cause the patient to fall further if the patient attempts to climb over the rails ...."

Based on record review and interview the hospital failed to follow hospital policy and procedure for notification of the attending physician that her patient (#5) being placed in restraints by the Hospitalist as evidenced by the lack of documentation in the medical record for 1 of 1 patient in restraints in a total of 6 sampled medical records. (Patient #5). Findings:

Review of the nurses' notes dated/timed 03/20/10 at 0315 (3:15am) revealed Patient #5 had been found on the floor of her room while attempting to go to the bathroom. Further review revealed S13, Hospitalist had been on the unit at the time of Patient #5's fall.

Review of preprinted "Physician Orders Restraints" dated/timed 03/22/10 at 2000 (8:00 p.m.) revealed the following: " 1. Patient is at risk for harm to self and alternatives to restraints exhausted. 2. Apply least restrictive device: Vest Restraint is checked and Left and Right Soft Wrist (restraints) are checked. 3. When patient is no longer at risk for harm to self/others, restraints may be removed early" and received as a verbal by S27 RN, House Supervisor from S13MD the Hospitalist on the unit at the time of the fall.

Review of the nurses notes indicate that S13MD was on the floor at the time of the fall on 03/22/10 of patient #5. Review of the Physician's Progress notes revealed S13MD was notified of the fall of patient #5. There is no documentation of notification of S28MD, the attending physician for that his patient had been restrained.

Based on interview the hospital failed to ensure that staff had documented demonstration of competency to apply or remove restraints. Findings:

Review of a PT note for 03/23/10 at 1330 (1:30 p.m.) by S21PTA revealed under daily note comment: " after removing wrist restraints and attempting to sit EOB (edge of bed) Pt became combative. Pt hitting and digging with fingernails. Unable to secure wrist restraints. Notified sitter and she will watch Pt until restraints can be reapplied. "

Review of a hospital policy titled " Restraint/Medical-Surgical " , policy number TX-A-350, issued (no date), approved date 05/01, last revised 10/09, presented as current policy reads in part: " Clinical justification for the restraint; ......Application of Restraints/Safety. Restraints may be utilized by members of the Health Care Team who have demonstrated competence in restraint application... "

In an interview on 04/13/10 at 1:40 p.m. with the DON she confirmed that neither the PTA nor the sitter in the room with patient #5 had training to apply or remove restraints.

Based on record review and staff interview the facility failed to measure, analyze, and track quality indicators for patient falls as evidenced by no documentation the data had been compared or analyzed to identify trends. Findings:

Review of the Patient Slip/Fall data reports labeled January 2010, February 2010, and March 2010 revealed the data collected was broken down by location, time of incident, patient data, reason for incident, and components of the facilities policy and procedure related to patient falls. Further review of the reports revealed the data had been collected and reported on a monthly basis without documented evidence the information had been compared or analyzed for possible trends as part of the hospital's QA/PI (Quality Assurance/Performance Improvement) process.

The facilities Patient Slip/Fall data reports labeled January 2010, February 2010, and March 2010 were reviewed. The slip/fall data that was collected was broken down by location, time of incident, patient data, reason for incident, and components of the facilities policy and procedure related to patient falls. Each report only contained data for that particular month that it was collected for. It was noted that there was no evidence that the data was compared, analyzed and/or tracked as part of the facilities QA process.

In a face to face interview on 04/16/10 at 12:10p.m. S11RN Risk Management (after review of the reports) confirmed that she does not compare and/or track data on a monthly or quarterly basis.

Based on record review and interview, the facility failed to incorporate accurate quality indicator data for patient falls by failing to identify 2 of 6 patient falls (fall #2 for patient #4 and fall #2 for patient #5) identified by the surveyors. Findings:

Review of the Meditech Patient Notification Log revealed there was no incident report filled out for the fall of patient #5 on 03/20/10 at 3:15 a.m.

In an interview on 04/14/10 at 9:20 a.m. with the DON she confirmed that there was no variance/incident report filled out for this fall per hospital policy.

Review of the Meditech Patient Notification Log revealed there was no Incident Report written for Patient #4's fall on 3/11/10 at 12:00 a.m. (0000).

S33RN reviewed Patient #4's nursing care on 3/10/10 and 3/11/10. She verified she had provided Patient #4's nursing care on 3/11/10 from 7:00 p.m. to 7:00 a.m. (night shift). She stated it was the hospital's policy to fill out an Incident Report after all patient falls. She confirmed there was no Incident Report filed on Patient #4's fall on 3/11/10 at 12:00 a.m.

Review of the medical records revealed there were 6 patient falls in the hospital for the month of March 2010.

In an interview on 04/14/10 at 2:20 p.m. with S2DON and S11RN, Risk Management/QA it was confirmed that there were no "Meditech Patient Notification" (variance/incident reporting system) forms filled out by the staff for 2 of 6 patient falls. During the same interview it was confirmed that failing to identify these falls and incorporate the data would lead to inaccurate QA data for the month of March 2010.

Based on record review and interview, the facility failed to monitor the effectiveness and safety of the services provided for patient falls as evidenced in the continued high fall rate for Unit 42. Findings:

A review of the Action Plan for slips/falls on Unit 42 for January 2010 revealed.... "1. the unit was going to continue to use non-skid socks, yellow arm band and yellow flag as indicators of fall risk patients. Continue to educate all associates/departments. 2. Continue to address in unit monthly meeting, increased patient falls. 3. Continue to encourage associates to admit/move patients with impulsivity, cognitive impairment, with poor insight into their impairment and disability, to a room closer to nursing station and use bed alarm at all times when patient is back in bed. 4. Continue to do hourly and environmental rounding addressing ..clutter and bed alarm activation. 5. Continue to assess patient's coordination and balance before assisting with transfer and mobility. 6. Continue to encourage all associates to complete post fall assessments, event charting, patient notification of MD, patient's family, Unit manager......".

A review of the Slip/Fall data collected for February and March of 2010 revealed no documented evidence the facility had tracked and/or trended the data to determine if the interventions were effective in reducing the number of patient falls.

In a face to face interview on 04/16/10 at 12:p.m. S11RN, Risk Management confirmed that she does not compare and/or track data on a monthly or quarterly basis.

Based on record review and interview the facility failed to use the data that was collected for slips/falls to identify opportunities for improvement and to make changes that would lead to such improvements. Findings:

Review of the facilities Patient Slip/Fall report dated January 2010 revealed 10 of the 20 documented falls occurred on Unit 43. According to the report, 9 patients fell while moving to/from the bathroom/BSC (bedside commode) and 7 were falls from the bed. Sixteen of the 20 patients who fell were on fall precautions at the time of the falls. A review of the January 2010 Action Plan for Slips/Falls on Unit a revealed that the 11 actions taken were all previous actions that were being continued. Further review of the action plan revealed no documented evidence any new interventions had been implemented.

Review of the facilities Patient Slip/Fall report dated February 2010 revealed 6 of 15 documented falls occurred on Unit 42. According to the report, 5 patients fell while moving to/from the bathroom/BSC and 5 were falls from the bed. All 15 falls patients were on fall precautions at the time of their falls. This data report was reviewed with S11RN, Risk Management, on 4/16/2010 at 12:10p.m.. During this review, S11RN, Risk Management, stated that the action plan was to discuss and reiterate hourly rounds which were already in place prior to this report. She stated that they discussed the need to implement a revised policy for falls. According to S11RN this policy had not been implemented as of 4/16/10 and the fall committee had not recommended any other interventions for the number of falls shown on the February 2010 report.

Review of the facilities Patient Slip/Fall report dated March 2010 revealed 6 of 13 documented falls occurred on Units 42 and 43. According to S11RN, Risk Management, the March data has not been presented to the Fall/QA committee as of 4/16/10.

Based on record review and interview, the facility failed to take actions aimed at performance improvement for patients with falls. Findings:

Review of the facilities Patient Slip/Fall report dated January 2010 revealed that 10 out of the 20 documented falls occurred on Unit 43. According to the report, 9 patients fell while moving to/from the bathroom/BSC (bedside commode) and 7 were falls from the bed. Sixteen of the 20 patients who fell were on fall precautions at the time of the falls. A review of the January 2010 Action Plan for Slips/Falls on Unit 42 revealed that the 11 actions taken were all previous actions that were being continued. There is no documentation on new interventions/actions.

Review of the facilities Patient Slip/Fall report dated February 2010 revealed 6 out of 15 documented falls occurred on Unit 42. According to the report, 5 patients fell while moving to/from the bathroom/BSC (Bed Side Commode) and 5 were falls from the bed. All 15 falls were patients who were on fall precautions at the time of their falls. This data report was reviewed with S11RN, Risk Management, on 4/16/2010 at 12:10 PM. During this review, S11RN, Risk Management, stated that the action plan was to discuss and reiterate hourly rounds which was already in place prior to this report. She stated that they discussed the need to implement a revised policy for falls. According to S11RN this policy has not been implemented as of 4/16/10 and the fall committee did not recommend any other interventions for the number of falls shown on the February 2010 report.

Review of the facilities Patient Slip/Fall report dated March 2010 revealed 6 of the 13 documented falls occurred on Units 42 and 43. According to S11RN, Risk Management, the March data has not been presented to the fall/QA committee as of 4/16/10.

Based on observation, record review and interview the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1) failing to provide adequate numbers of nursing staff to enable nurses to follow physicians orders for 1:1 patient/nurse ratio, follow hospital policies and procedure, and fall risk protocols for patients assessed at risk for falls or who had suffered a fall while hospitalized . This failure resulted in 3 of 5 patients falling and suffering injury. (patient #5 fell 3 times and was found attempting to climb over the side rails of her bed on numerous occasions with one fall while physician ordered 1:1 observation orders were not being followed, #4 fell twice in the hospital striking her head both times, (#3) had a fall with a broken tibula/fibula.) (see findings at A0392 and A0395)

2) failing to provide adequate nursing staff on the psychiatric unit for the night shift as evidenced by placing all Unit 54 patient beds that require LOS (Line of Sight), 1:1 and/or High Fall Risk in the hallway for 21 of 21 patients so staff would be able to visualize all patients; failing to staff Unit 43 according to the Unit's staffing matrix for 17 of 18 shifts (day, evening, night) covering the 6 days patient #5 was in the hospital resulting in physician ordered 1:1 staffing not being followed, the patient falling three times (with injury), and the patient being found multiple times climbing over the 4 raised side rails. (03/18/10 - 03/23/10). (see findings at A0392)

3) failing to ensure that a RN comprehensively assessed each patient after the patient experienced a fall. (#4, #5) (see findings at A0395)

4) failing to ensure the implementation of nursing care plans that were based on identified patient needs and problems and the hospital's fall risk protocol; failing to update and revise the care plan as required in response to changes in patient needs and problems; and failing to identify common causes of falls (night shift, wanting to go to the bathroom, etc.) and implement new approaches and interventions to prevent further falls. This failure resulted in 2 of 5 patients sampled (#5, #4) having continued falls with injuries as well as continued attempts to climb over side rails without changes in interventions or approaches on the patients care plans. (see findings at A0396)

5) failing to maintain patient #4 in Line of Sight (LOS) observation on 3/9/10 and 3/11/10 which resulted in a fall each time LOS was not maintianed and by failing to notify the physician that the patient had hit the back of her head when she fell the first time (3/9/10) and had a change in her mental status from alert to drowsy 40 minutes later and by failing to notify the physician that the patient had hit the back of her head when she fell and had a change in her mental status from alert to drowsy 3 hours after her second fall on 3/11/10 for 1 of 5 sampled focused fall patients. ( #4) (see findings at A0395)

An Immediate Jeopardy situation was identified on 04/15/10 at 5:10 p.m. and the following were advised of the IJ: S1Administrator; S2DON; S3MD, VPMA; and S4RN, Asst. Admin. Operations. The Immediate Jeopardy situation was the result of the following:

The facility failed to 1) Ensure that hospital staffing meets the needs of the patients identified as high risk for falls and/or needing increased observation status which resulted in:

a) Failing to follow Physician Orders for maintaining a patient on one-to-one observation status to prevent falls resulting in injury to patient #5's left hip, failing to keep patient #4 in line-of-sight observation resulting in a fall with head injury, failing to provide ambulation assistance to patient #3 resulting in a fall with a leg fracture, failing to ensure patient #2 was kept in line-of-sight observation per nursing judgement pending physician order resulting in a fall.

b) Failing to room psychiatric patients in licensed rooms during the night shift as evidenced by all patients identified line-of-sight or high risk for falls requiring increased observation status being placed in hallway due to lack of staff per interviews with the Director of Nursing, Unit Director, Psychiatric Nurse, and Mental Health Technician.

c) Failing to ensure restraints were not used for staff convenience and without physician order by restraining patient #5 and #2 for staff convenience per a physician order and patient #5 without a physician's order by raising all 4 side rails.

2) Ensure that each patient who fell received a comprehensive assessment.

a) Failing to identify the extent and location of injuries for patient #4 and #5 resulting in patient #4 nor receiving a CT of her head until after her second fall striking her head and patient #5 not receiving an x-ray of her left hip after her second fall and the nurse's identified bruising and pain to the left hip.

b) failure to initiate/update the care plan and implement interventions to prevent falls and/or subsequent as evidenced by patient #5 falling 3 times and patient #4 falling twice.

3) The QA program fails to identify all falls, collect accurate fall data, trend for commonalities and/or contributing factors, and implement corrective action. The hospital staff failed to complete incident reports as per facility policy for 2 out of 6 identified falls (the second falls of patients #5 and #4).

The hospital submitted an acceptable Plan of Removal for the Immediate Jeopardy on 04/19/10 at 11:10 a.m. Present were S1Administrator; S2DON; S4RN, Asst. Admin. Operations; and S5RN. The Plan of Removal included:

1. Ensure that hospital staffing meets the needs of the patients as identified as high risk for falls and/or needing increased observation status.

a) All orders for one-to-one observation will be followed immediately. We will also contract with agencies to provide qualified staff if needed to comply with one-to-one orders. Timeline: Contract executed on 04/16/10. Responsible person: (name)

b) Plan 24 hours in advance for one-to-one needs. Nurse will immediately notify house supervisor when order for one-to-one is noted so that planning can begin. Educate all nursing staff and supervisors. Educators and Department directors are responsible for assuring this education is complete. Evidence of education compliance will be documented on education signature forms. Timeline: Education will begin immediately for all relevant staff as staff report to work until 100% of the designated staff have completed education. Responsible person: (S2DON)

c) Add mobility orders to the Unit 54 admission orders. Physical Therapy will educate Unit 54 medical staff and Unit 54 nursing staff regarding mobility definitions and addressing mobility needs in the plan of care. Timeline: Education will begin immediately for all relevant staff as staff report to work until 100% of the designated staff have completed education. Responsible Person: (S7RN, Unit 54 Director)

d) Patients on Unit 54 will immediately be placed back in rooms at night and assessments and interventions will be completed per fall policy. Standard q 15 minute checks will continue per standard of care. Director/House Supervisor will be responsible for assessing staffing by shift taking into consideration census and patient acuity. Any staffing changes based upon acuity will be documented on the house supervisor report. Timeline: 04/16/10 Responsible Person: (S7RN, Unit 54 Director)

e) Educate nurses about appropriate use of restraints in accordance with policy. Example: restraints are never to be used in lieu of one-to-one monitoring for staff convenience. Charge nurse will assess each patient prior to restraint use and assure that all alternatives have been attempted. Educate all staff in direct patient care roles about the appropriate use of all 4 side rails. Any restrained patient will be reported to the house supervisor. Educators and Department directors are assuring this education is complete. Evidence of education compliance will be documented on education signature forms. Timeline: Education will begin immediately for all relevant staff as staff report to work until 100% of the designated staff have completed education. Responsible Person: (S2DON and S4RN, Asst. Admin Ops)

f) House supervisor report will include falls, restraints, or patients requiring one-to-one monitoring. The day shift House Supervisor will report these to Leadership. (S8RN, Unit 43 Director) will complete the form and the education. Timeline: Implement immediately with education completed by 04/23/10. Responsible Person: (S8RN, Unit 43 Director)

2) Ensure that each patient who falls receives a comprehensive assessment.

a) Educate all nursing staff about assessment activities required after a fall according to the falls protocol. Educators and Department directors are responsible for assuring this education is complete. Evidence of education compliance will be documented on education signature forms. Timeline: Education will begin immediately for all relevant staff as staff report to work until 100% of the designated staff have completed education. Responsible Person: (S2DON)

b) After completion of Code White and variance form, the Code White Team will identify and assure documentation of any new/additional interventions to prevent any further falls. The Code White form will be revised to reflect these additional activities. Educate all nursing staff. Educators and Department directors are responsible for assuring this education is complete. Evidence of education compliance will be documented on education signature forms. Timeline: Education will begin immediately for all relevant staff as staff report to work until 100% of the designated staff have completed education. Responsible Person: (S2DON)

3. The QA program fails to identify all falls, collect accurate data, trend for commonalities and/or contributing factors, and implement corrective action.

a) The Unit Director and Risk Manager will complete an intense assessment after each fall, including review of the medical record, Code White sheet, and variance report by the next business day and forwarded to the Slips/Falls committee. Timeline: Implement immediately. Responsible Person: (S2DON and S11RN, Risk Mgmt/QA.)

b) The Director/House Supervisor will assure variance report for any fall is complete as part of the Code White process. Educate all nursing supervisors. Timeline: Implement immediately with education completed by 04/23/10. Responsible Person: (S8RN, Unit 43 Director)

c) Slips/Falls Committee will review aggregated data about falls to identify trends and potential improvement in processes monthly. Timeline: 04/20/10 Slips/Falls Committee. Responsible Person: (S11RN, Risk Mgmt./QA)

d) Recommendations from Slips/Falls Committee will be reported to Safety Committee, PIC, and Governing Board. Timeline: 04/22/10 Safety Committee, 05/13/10 PIC, 06/17/10 Governing Board. Responsible Person: (S5RN)

The Immediate Jeopardy was removed after the surveyor confirmed that the hospital implemented the above plan, but non-compliance remained at the condition level.

Based on record reviews and interviews the hospital failed to have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as evidenced by:

1) failing to have adequate staff available to provide increased observation status for a patient with one-to-one (1:1) physician orders for 1 of 5 focused sampled fall patients (#5)who sustained a fall prior to admission and multiple falls in the hospital.

2) failing to have adequate staff available to provide increased observation status for a patient with Line of site (LOS) on 3/9/10 and/or 3/11/10 for 1 of 5 focused sampled fall patients (#4) who fell twice in the hospital striking her head both times.

3) failing to provide ambulation assistance per hospital policy for 1 of 5 sampled patients (#3) resulting in a fall with a broken tibula/fibula.

4) failing to provide a patient with one-to-one (1:1) observation for 1 hour and 15 minutes on Unit 51 by using restraints in place of the 1:1 observation. (#2)

5) placing all Unit 54 patient beds that require LOS, 1:1 and/or High Fall Risk in the hallway so staff can see the patients during the night shift for 21 of 21 patients 6) failing to staff Unit 43 according to the Unit's staffing matrix for 17 of 18 shifts (day, evening, night) covering the 6 days patient #5 was in the hospital (03/18/10 - 03/23/10).

Findings:

1)

Patient #5

Review of the Admission Orders for patient #5 revealed the patient was admitted on 03/18/10 to S28MD with a diagnosis of Altered Mental status and CVA (cerebrovascular accident - stroke). Further orders included: " Physical Therapy and Occupational Therapy: Evaluate and treat " and " Physical Therapy and Occupational Therapy: Evaluate and treat in 24 hours. " Further review of the physician admission orders under " Activity " revealed the physician gave no orders for the activity level of patient #5.

Further review of handwritten Physician Orders dated 03/18/10 at 1930 (7:30 p.m.) revealed: " ...5. Fall Precautions .... "

Review of the nursing notes for 03/18/10 at 1745 (5:45) revealed an admission assessment by S12RN. Review of the assessment revealed the following documentation: " Skin warm and dry. ...no evidence of rashes, lesions or skin breakdown. Ambulation ability - assistive device. Weight bearing ability - Full. Gait pattern - Shuffling. History of falls - No. " The fall risk score for patient #5 was 20. (Fall risk score of 0 - 24 is defined as low risk - basic interventions. 25 - 44 is Moderate risk - standard interventions. and > 44 is High risk - High Risk interventions)

In an interview on 04/14/10 at 9:10 a.m. S12RN confirmed that if she had added the recent history of a fall that this would have raised the Fall Risk Score for Patient #5 to 45, in the High Risk for Fall range. S12, RN, further indicated that 2 staff members attempted to stand patient #5 to move her from the ER stretcher to the bed in the room. S12RN indicated that even with a 2 person assist it was determined that patient #5 was too weak to perform the transfer. Patient #5 was seated back on the ER stretcher and moved to the hospital bed in the room by sliding her over.

In the same interview S12RN confirmed that her 03/18/10 at 1800 (6:00 p.m.) documentation of " Side Rails - Upper Times Two - Lower Times Two " ( is restraints and she had no physician order for restraint.

Review of the nursing documentation for 03/18/10 night shift by S14RN revealed the following: " 03/18/10 at 1949 (7:49 p.m.) Ambulation ability - Assistive device. Weight Bearing ability - full. Gait pattern - shuffling. Skin Location Modifier: Left. Skin Location Body Site: Knee. Skin Problem: SWELLING. History of Falls - Yes. Fall Risk Screening Score - 45 (high risk).

Further review of nursing documentation for 03/18/10 at 2040 (8:40 p.m.) read: " Patient was found sitting on floor " I need to get up and go. " Also " You don ' t look like my family. " Reoriented. Helped back into bed. Dr. and daughter notified per Code White Form. No distress noted. Verbally reoriented by house supervisor and nursing staff. However difficult due to patient hard of hearing with some possible short term memory loss. Will continue to monitor. " Documentation for 03/18/10 at 2045 (8:45 p.m.) under " Perform Neuro Check " reads: " S/P (status post) Fall - assessment done. No change in neurological status post fall. Very hard of hearing. "

In an interview on 04/15/10 at 8:20 a.m. with S27RN, Charge Nurse, she confirmed that 4 side rails were up and that this is considered restraints. S27 further stated that raising 4 side rails up on the patient's bed would increase the patient's risk of injury due to a potentially higher fall. S27RN confirmed there were no changes made to the care plan of Patient #5. S27RN also confirmed there was no documented head to toe assessment documented after the fall of Patient #5.

Review of the Meditech Patient Notification (incident report) revealed that Patient #5 was " found on floor in patients room. " Nature of injury is documented as " no injury noted. " Fall information is documented as " Fell from: bed. Condition prior to fall: confused. Side Rail Position: 4 up. Was Fall Assessment completed prior to Fall: Y (yes). Was Fall Assessment Completed after Fall: Y. " Documentation entered by S27RN Charge Nurse on 03/18/10 at 2147 (9:47 p.m.) reads as follows: " called to room by nurse (S26RN) patient on floor, states she was trying to go to the bathroom to urinate (has a foley). Reoriented and placed back in bed with 2 person assist. Vitals stable. "

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/18/10 at 2045 (8:45 p.m.) ....found on floor with all 4 rails up - trying to go to bathroom ....to void (has foley). " There is no changes documented in the plan of care of Patient #5 after each fall or after she is repeatedly found attempting to go over the side rails.

There were no documentation of " customized fall prevention interventions " per the Hospital Clinical Policy: Falls Protocol. There was no documentation that the Registered Nurse implemented and over saw individualized patient fall prevention, determined the factors influencing the risk and established an appropriate plan of care with interventions specific to the fall risk level.

The nurses failed to follow the Hospital Clinical Policy: Falls Protocol by using side rails " because they are considered restraints and increase the possibility of patient entrapment. Additionally, full side rails can cause the patient to fall further if the patient attempts to climb over the rails. "

Further review of the medical record of Patient #5 revealed there was no documentation of nursing instituting one-to one nursing for a patient with a recent fall and at risk for another fall, requesting the family stay with the patient, the patient being moved closer to the nursing station, scheduled toileting, increased frequency of staffing rounds, reduced patient load for primary nurse, team nursing approach (nurses taking turns charting in the patient at high risk for falls room), a head to toe assessment after the fall, documentation of interventions and monitoring of the effectiveness of the interventions. There was no documentation the patient/family viewed the " fall risk video " or was given the handout " A Guide to preventing Falls " per hospital policy. There is no documentation of notification of the physician of Patient #5 having deterioration of her altered mobility status or persistent behaviors of climbing over the rails of the bed.

Further review of the document revealed that on 04/12/10 at 8:29 a.m. (the 26th day since the fall of patient and the day of entry on the complaint) S8RN, Unit Director, entered the following: " Patient was a high risk for falls. (review of the admission assessment fall risk revealed Patient #5 was documented as having a fall risk score of 20 which is low risk. The initial assessment failed to include the recent history of a fall which would have placed Patient #5 in the high risk for falls category) Patient had soaks (socks) on. Patient was educated not to get out of bed, but was confused. Alone in the room. A Code White was called. "

In an interview on 04/14/10 at 2:00 p.m. S8RN, Unit 43 Director, stated that there was no thorough investigation done on the 03/18/10 fall (1st fall) of Patient #5. The DON was present for this interview.

Review of the next nursing documentation for 03/18/10 at 2200 by S14RN revealed the following under Neuro Check Comment - " No change in Neurological status post fall. Still needs reorienting which is difficult due to being very hard of hearing. "

Review of the next nursing documentation for 03/18/10 at 2215 (10:15 p.m.) by S14RN revealed the following under Rounding comment - " Watching television. Reoriented. Instructed repeatedly to not get out of bed without help. "

Review of the next nursing documentation for 03/18/10 at 2215 (10:15 p.m.) by S14RN revealed the following under Rounding comment - " Patient was found by Charge Nurse attempting to crawl over foot of bed. Repositioned back into bed. New bed with alarm found and replaced for patient. Will have nursing closely observe patient at bedside. "

Review of the nursing documentation for 03/19/10 for 0000 (midnight), 0100 (1:00 a.m.), 0200 (2:00 a.m.), and 0300 (3:00 a.m.) all revealed " nurse observing from bedside. "

Review of the nursing documentation by S14RN for 03/19/10 at 0300 (3:00 a.m.) under Rounding comment reads: " Patient pulled out IV. (intravenous catheter) IV restarted per (S27RN, Charge Nurse). Patient repeatedly reoriented. " I still need to get up and go outside " . Will continue to monitor at bedside. "

Review of the nursing documentation by S14RN for 03/19/10 at 0400 (4:00 a.m.) under Rounding comment reads: " Patient (#5) moving off bed. Stopped by nurse at bedside. Continuing to reorient. "

Review of the nursing documentation by S14RN for 03/19/10 at 0500 (5:00 a.m.) under Rounding comment reads: " nursing staff still at bedside. "

S14RN failed to show up for his scheduled interview with the surveyor's on 04/15/10. The hospital was not able to reschedule S14RN for interview. The DON stated S14RN was scheduled the previous day to be in this a.m. but he was a no show. Review of the medical record for Patient #5 revealed S14RN was the nurse on duty for 2 of 3 of Patient #5's falls.

Review of the Physical Therapist documentation for the day shift on 03/19/10 at 1100 (11:00 a.m.) by S19PT revealed the following: " Pt. is a 94 Y/O (year old) admitted after she couldn ' t get up from a fall at home and was found on the floor by a family member. Prior Mobility Status Level - Independent. Prior Activity Level - ADL ' s. (activities of daily living) Prior Living Arrangements - Home Alone. Living Situation Comment - ..Pt. lives alone, daughter ' s check in daily to help with cleaning and cooking. Are you having pain now? Y (yes) Pt. c/o (complain of) L (left) Leg Pain. Nursing Informed of Pain? Y. Face - Occasional Grimace/Frown. Transfers to chair. Transfers from bed. Additional Functional Mobility Assistance Required - Moderate Assist. Assistive Devices - Rolling Walker, Gait Belt. Pt. T/Ferred (transferred) bed to chair with Mod (moderate) assist X2. (two therapist helping) Pt. c/o pain L LE (left lower extremity) with mobilization. Also when calf is squeezed. Nursing notified. Recommend D.C. (discharge) to NH (nursing home) with OT/PT. "

Review of the " Hospitalist Assessment Form " dated/timed 03/19/10 at 12:30 p.m. by S28MD revealed " Gait - non-ambulatory. PT eval still pending. There is no documentation by the physician responsible for the care of Patient #5 that she was notified that Patient #5 was found on the floor on 03/18/10 at 2040 (8:40 p.m.)

Review of the nursing documentation for 03/19/10 at 1418 (2:18 p.m.) by S40RN, revealed " very weak, unable to put full weight on legs and Left Knee Swelling. "

Review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/19/10 at 1600 (4:00 p.m.) under Rounding Comment that read: " Found with legs over side rails attempting to get out of bed. Encouraged to remain in bed. No signs distress noted. Monitoring. " Further review of the " Shift Physical Assessment " dated/timed 03/19/10 at 2000 (8:00 p.m.) revealed: " Left Knee Swelling. Side Rails up - Upper Times Two - Lower Times Two. " Review of the " Nursing Rounds " dated/timed 03/19/10 at 2000 (8:00 p.m.) revealed: " Side Rails up - Upper Times Two - Lower Times One. " The Fall Risk Score is documented as 45 (high risk) on 03/19/10 at 2000 (8:00 p.m.)

Further review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/20/10 at 0000 (midnight) under Rounding Comment that read: " Found with legs over side rails attempting to get out of bed. Repositioned and pulled up in bed. Encouraged to remain in bed. No signs distress noted. Monitoring. "

Further review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/20/10 at 0315 (3:15 a.m.) under Rounding Comment that read: " Found on floor. States " I was trying to go to the bathroom. Code White protocol initiated. Physician and family notified. No signs of distress noted. 1:1 order noted. Sitter at bedside monitoring. "

Review of the Meditech Patient Notification Log revealed there was no incident report filled out for the fall of Patient #5 on 03/20/10 at 3:15 a.m.

Review of the Code White form used by the hospital revealed: " Date/Time of Fall: 03/20/10 at 0315 (3:15 a.m.) ...Patient response to event: confused. Staff present at time of fall: No. Risk factors for Fall: Previous fall, confused. Side rails in Use: 4. "

Review of physician orders dated/timed 03/20/10 at 0345 (3:45 a.m.) revealed a telephone order from S13MD documented by S14RN that read " 1:1 (one to one observation) and x-ray of L (left) knee and R (right) hip.

In an interview with S13MD, Hospitalist, he stated that the nurse had documented the wrong hip to be x-rayed. S13MD stated he ordered the Left hip to be x-rayed as he would expect blunt force from a fall onto the left knee to be projected to the left hip. S13MD could not explain why he authenticated the same order (without date or time) if it was not correct.

Review of the Fall Risk Assessment dated/timed 03/20/10 at 0338 (3:38 a.m.) revealed Patient #5 now had a Fall Risk score of 75.

S14RN failed to show up for his scheduled interview with the surveyor's. The hospital was not able to reschedule S14RN for interview.

Review of the physician ' s Progress Note documented for 03/20/10 by S28MD, Attending Physician, revealed " fell again 3X (times) she advises -> has 1:1 now. x-ray of hip negative. " There is no documentation that the physician responsible for the care of Patient #5 was notified of the L Hip pain of Patient #5. (and that the x-ray was done on the R hip)

Review of the nursing documentation for 03/20/10 day shift by S16LPN dated/timed 03/20/10 at 0800 (8:00 a.m.) revealed the following " Left Knee Swelling and Left Hip Bruise. left hip and left knee tender to touch s/p fall. " There is no documentation of notification of the physician responsible for the care of Patient #5 of the new assessment findings on the Left Hip. Under " Additional Pain Information " S16LPN documented " no complaints of pain, hurts when left knee or left hip is touched. "

In an interview on 04/12/10 at 2:00 p.m. with S16LPN he stated he could not remember if he was given the assessment findings of left hip bruise/pain in report. He further indicated that if it was a new finding he would notify the physician responsible for the care of the patient.

In an interview on 04/13/10 at 1:50 p.m. with the DON and S8RN, Unit 54 Director, both stated they would expect physician notification of the change in status/assessment of Patient #5.

The DON further indicated in an interview on 04/13/10 at 3:00 p.m. that Patient #5 was at risk to fall, that she was left alone in the room and that she fell as a result of this.

In an interview on 04/14/10 at 9:20 a.m. with the DON she confirmed that there was no variance/incident report filled out for this fall per hospital policy.

Review of the Fall Risk Assessment dated/timed 03/20/10 at 0800 (8:00 a.m.) revealed Patient #5 had a Fall Risk Score of 95.

Review of the nursing documentation for 03/20/10 night shift by S14RN dated/timed 03/20/10 at 2000 (8:00 p.m.) revealed: " bilateral lower extremity push weakness, left knee swelling, left hip bruising. "

Review of the documentation by S14RN dated/timed 03/20/10 at 2000 (8:00 p.m.), 2200 (10:00 p.m.), 0000 (midnight), 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) under Nursing Rounds - Rounding Comment revealed: " Resting in bed. Family at bedside ... ... "

Review of the nursing documentation for 03/21/10 day shift by S15LPN dated/timed 03/21/10 at 0900 (9:00 a.m.) revealed patient #5 had a Fall Risk Score of 75. Review of the nursing documentation for 03/21/10 at 1000 (10:00 a.m.) by S15LPN revealed " Left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Further review of the nursing documentation for 03/21/10 at 1800 (6:00 p.m.) revealed " Bedbath given - Small skin tear noted on buttocks - placed on pillows. " There is no documentation of notification of the physician responsible for the care of patient #5 of the skin tear..

Review of the physician ' s Progress Note dated 03/21/10 at 10:30 a.m. revealed " Fall - Secondary to generalized weakness. "

Review of the nursing documentation for 03/21/10 night shift by S14RN dated/timed 03/21/10 at 2000 (8:00 p.m.) revealed: " ...No evidence of Rashes, Lesions, or Skin Breakdown. Left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Review of the Fall Risk Assessment dated/timed 03/21/10 at 2000 (8:00 p.m.) revealed patient #5 had a Fall Risk Score of 95.

Review of the nursing documentation for 03/22/10 at 0000 (midnight), 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) revealed " sitter at bedside. "

Review of the PT documentation for 03/22/10 at 1105 (11:05 a.m.) revealed " treatment not performed " and the reason documented is " maintenance working in room. " Further review of the PT documentation for 03/22/10 at 1135 (11:35 a.m.) revealed " treatment not performed " and the reason documented is " Patient Declined. " There is no documentation of notification of the physician responsible for the care of Patient #5 that PT was not done as ordered.

Review of physician orders written by S29MD dated/timed 03/22/10 at 1:00 p.m. revealed the physician again ordered " Fall Precautions " .

Review of the physician ' s Progress Note for 03/22/10 (no time indicated) by S13MD, Hospitalist, revealed " s/p fall. Exam: no focal neurological deficit. No evidence of trauma. Vest restraint. "

Review of the nursing documentation for 03/22/10 day shift by S23RN at 1600 (4:00 p.m.) revealed " family at chairside." Pt. sitting up in chair in room. Very confused and not talking clear. Will move Pt. closer to nurses ' station. "

Review of the nursing documentation for 03/22/10 day shift by S40RN revealed documentation timed at 1611 (4:11 p.m.) that read in part: " family at bedside. "

Review of nursing documentation on 03/22/10 at 1800 (6:00 p.m.) by S23RN revealed " move pt. to room 4322 for safety across from nurse ' s station for closer monitoring. "

In an interview on 04/14/10 at 8:50 a.m. with S23RN she stated she moved Patient #5 from room 4306 to room 4322 on the evening shift on 03/22/10. She further indicated the move took 5 minutes. S23RN stated she told the family if they left the room to leave the door open and leave light on. S23RN further indicated that Patient #5 was found on the floor during shift change. S23RN stated she was aware of the physician ' s order for 1:1 observation for Patient #5 and that the physician was not notified the order was not being followed.

Review of the nursing documentation for 03/22/10 night shift by S22LPN at 1900 (7:00 p.m.) revealed the following: " left knee swelling, left hip bruise, left hip and knee tender to touch s/p fall. "

Documentation by S22LPN for 03/22/10 at 1900 (7:00 p.m.) also included the following: " Dr. is on the floor at the time of the Code White and ordered the vest restraints on the pt. This is her 5th time falling in this hospital. 1:1 is ordered by (name). House Supervisor states that they don ' t have the staffing to cover a 1:1. " Documentation for the same date/time by S22LPN under " Medical/Surgical Healing Restraints - Alternative Strategies Attempted " include " Family/Sitter at bedside. " Under " Demonstrated Patient Behavior " S22LPN documented " Climbing Out of Bed/Chair. "

Review of preprinted " Physician Orders Restraints " dated/timed 03/22/10 at 2000 (8:00 p.m.) revealed the following: " 1. Patient is at risk for harm to self and alternatives to restraints exhausted. 2. Apply least restrictive device: Vest Restraint is checked and Left and Right Soft Wrist (restraints) are checked. 3. When patient is no longer at risk for harm to self/others, restraints may be removed early. " Handwritten under this order is " or if 1:1 is in room. " (as ordered by the physician on 03/20/10 at 3:45 a.m.) Further review revealed this was a verbal order taken by S27RN, House Supervisor from S13MD, the same physician who ordered 1:1 supervision for patient #5 on 03/20/10 at 3:45 a.m.

In an interview on 04/14/10 at 10:40 a.m. with S13MD he stated that the " Patient (#5) fell due to the staff not following his order for 1:1 observation. " (dated 03/20/10)

Review of the Meditech Patient Notification Form (incident report) revealed an event date of 03/22/10 at 1930 (7:30 p.m.). Location is listed as room 4322. Nature of injury is " No Injury Noted. " Further review revealed the following documentation: " Fell from: bed. Condition prior to fall: confused. Side rail position: 4 up. Was Fall Assessment completed prior to fall? N (no). Was fall assessment completed after fall? Y. " The following documentation was entered by S27RN, Charge Nurse on 03/22/10 at 2000 (8:00 p.m.): " Patient found on floor by bed. States she was trying to go to bathroom. Put back in bed and reoriented. " S8RN, Unit 43 Director documented the following on 03/25/10 at 9:32 a.m.: " Patient was confused alone in room. (the physician had ordered 1:1 supervision on 03/20/10) Family and physician notified of fall. Code White called. Patient has slipper soaks (sp?) and yellow flag used. Patient moved closer to nurse station. (this move from room 4306 to 4322 occurred prior to the patient fall) Patient placed back on a 1:1. No narcotics given. "

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/22/10 at 1930 (7:30 p.m.) ....found on floor ...Medical/nursing actions: back to bed, reoriented ...Staff present at time of fall: No ...Risk factors for fall: disorientation ....Siderails in use: 4. "

In an interview on 04/14/10 at 2:00 p.m. S8RN, Unit 43 Director was asked if there was an investigation into the fall of Patient #5 on 03/22/10 (fall #3). She replied she was in the process of performing the investigation. She was asked to provide the documentation to the surveyor ' s. S8RN, Unit 43 Director produced a copy of the 2nd Grievance Report from the family of Patient #5 with a few handwritten notes.

Review of the nursing documentation for 03/22/10 at 2200 (10:00 p.m.) by S22LPN under Rounding Comment reads: " Resting in bed. Alone in room. Restraints applied. Pt. has pulled out her IV. Wrist restraints applied. "

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated that no one was in the room per the physician ' s order for 1:1 supervision on the night shift for 03/22/10. S22LPN stated she could not remember if she notified the physician that they were not in compliance with his order for 1:1 supervision of Patient #5. S22LPN stated that not following the physician ' s order contributed to the fall of Patient #5 on 03/22/10. The DON and Director of Unit 43 were present for this interview.

Review of the physician ' s Progress Note dated 03/23/10 at 11:15 a.m. by S13MD, Hospitalist, revealed " pt fell last night. No injury.

Review of the nursing documentation for 03/23/10 day shift by S23RN dated/timed 03/23/10 at 0800 (8:00 a.m.) reads in part: " left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Further review of the documentation by S23RN for 03/23/10 at 0800 (8:00 a.m.) under Rounding Comments revealed: " Awake. Alert. Oriented to person, and confused. ... ...Bil. (bilateral) wrist restraints intact. Pt. pulls out all tubing and climbs out of bed per self and unable to walk. 1:1 supervision in room with pt. Daughter at bedside. Pt. pulling off 02 at this time. Nurse placed it back. "

Review of a PT note for 03/23/10 at 1330 (1:30 p.m.) by S21PTA revealed under daily note comment: " after removing wrist restraints and attempting to sit EOB (edge of bed) Pt became combative. Pt hitting and digging with fingernails. Unable to secure wrist restraints. Notified sitter and she will watch Pt until restraints can be reapplied. "

In an interview on 04/13/10 at 1:40 p.m. with the DON she confirmed that neither the PTA nor the sitter in the room with patient #5 had training to apply or remove restraints.

Review of the documentation by S23RN for 03/23/10 at 1530 (3:30 p.m.) under Nursing Rounds - Rounding Comment read: " assist to chair in bedroom. Daughter and 1:1 sitter at bedside. Wrist restraints off at this time. " Under Additional restraint Information documented on 03/23/10 at 1530 (3:30 p.m.) S23RN documented " Verbal contract with Pt. and Daughter to have Pt. sit in chair without restraints at this time. With also 1:1 sitter at bedside to monitor pulling of tubes and attempting to get up. "

Review of the nursing documentation for 03/23/10 night shift by S22LPN revealed documentation for 03/23/10 at 1900 (7:00 p.m.) that read in part: " left knee swelling, left hip bruise, resting in bed, 1:1 in room ... " Further review of the documentation by S22LPN on 03/23/10 at 2200 (10:00 p.m.), 0000 (midnight), 03/24/10 at 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) revealed 1:1 in room.

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated she could not remember if she notified the physician responsible for the care of patient #5 of the left hip bruise/pain. S22LPN further indicated that there was 1:1 supervision in the room of patient #5 on the night of 03/23/10 and that patient #5 had no falls that night. S22LPN further stated that 1:1 supervision was effective in keeping patient #5 from falling.

Review of the nursing documentation for 03/24/10 day shift by S24LPN dated/timed 03/24/10 at 0800 (8:00 a.m.) read in part: " left knee swelling, left hip bruise. "

Review of the Discharge Education for Patient documented on 03/24/10 at 0905 (9:05 a.m.) revealed under Additional Activity Limitation Instructions " Fall Precaution. " Patient #5 was discharged to NH " a " .

In an interview on 04/14/10 at 2:30 p.m. with S24LPN she confirmed her documentation of left hip bruised. S24LPN further indicated she did not remember the Patient (#5) of if she notified the physician responsible for the care of the patient of the bruise.

Review of the Discharge Summary with a DD (date dictated) of 03/23/2010 (no time indicated) by S29MD revealed the following: " FINAL DIAGNOSES: 1. Altered mental status secondary to dementia.....3. Rhabdomyolosis, resolved.......5. Hypertension, stable. 6. Hypokalemia, resolved. 7. Severe pulmonary hypertension ...HOSPITAL COURSE: This is a 94 year old female with significant past history of hypertension. The patient was brought in by a family member due to altered mental status and a fall ... ...The patient is awake but oriented to people and place. The patient had overall weakness due to the age of 94......The patient had a fall last night but did not sustain any injury or fracture ....DISPOSITION: She (patient #5) will be discharged to Nursing Home tomorrow morning around 10 a.m. .....Activity will be as tolerated. Fall precautions. The patient needs close monitoring due to dementia ... "

Review of a hospital policy titled " One to One Guidelines " , policy number NR-1-2-20, issued 07/23/08, last revised 09/24/08, presented as current hospital policy, reads in part: " Purpose: The use of one-to-one sitters has become a common alternative to the application of restraints and to provide a care environment of increased safety. One-to-One usage has been used for patients at risk for falls without evidence of improved outcomes from alternative actions. NOTE: physical restraint will be used as a last resort for patient safety. Potential Reasons for One-to-One usage: ... ...Fall since admission with risk of another fall .....Standard of Care. The patient/care giver can expect the patient will be provided a safe care environment. Procedure/Process. A. One-to-One Use Decision-Making Process: 1. Patient exhibits ...fall risk, post fall. Nursing Staff institutes alternatives to one-to-one ....(C. Alternatives for ...fall risk: 1. Family asked to stay with patient. 2. Patient moved closer to nurses ' station. 3. Use of bed with bed alarm. 4. Clinical review of necessity of medical devices ...possibly discontinue device/line ....7. Pain management - comfort measures. 8. Address possible hunger .....10. Medication to reduce anxiety. 11. Increased frequency of staffing rounds. 12. Toileting schedule ... ...16. Patient load reduced for primary nurse of this patient- allows more time to be spent with this patient. 17. Team nursing approach - Staff taking turns charting in patients room. 18. Use of restraints. (Last resort)) ....2. Assessment of effectiveness of alternatives ...NO - RN completes one-to-one justification form. 3. RN contacts Nursing Director or House Supervisor and reviews ... ...approval? Yes - One-to-One used ....When a One -to-one order is written the nurse will collaborate with the physician to discuss other alternatives if indicated. If the physician does not feel comfortable with alternatives presented, the order for 1:1 will be followed.

Review of a hospital policy titled " Patient Falls Prevention " , policy number TX-A-480, issued 07/91, last revised 10/08, presented as current hospital policy, reads in part: " Standard of Care. The patient/caregiver can expect to have adequate precautions taken to prevent harm to patients at high risk for falls. Standard of Practice. The nursing staff will assess all patients, identify those who are high-risk for falls and implement precautions to prevent harm/injury. Procedure. I. The nurse will assess the patients at risk for falls: A. High-risk patient (includes but not limited to one or more of the following): over 70 years of age; confused and disoriented, hallucinations; altered mental status; recent history of falls; chronic disease; recent history of loss of consciousness, seizures; unsteady on feet, syncope; poor general health; sensory deficits; ...drugs (i.e., anti-hypertensive ...); ....decreased mobility. II. The nurse will assess the patient for fall risk on admission and daily during the hospital stay or more frequently if indicated by a change in patient status. Patients at high risk for falls will be identified by a neon yellow band to be placed on the same limb as the patient identification bracelet. III. The nursing staff will check a " high risk " patient every two hours and document nursing interventions in the ongoing assessment ...Safety Interventions. Keep call bell/light within patient ' s reach at all times and assure that the patient is able to use it ....Assist patient with transfers/ambulation as needed ....Keep night light on during evening/night hours. Patient/Family Instruction. 1. Provide " fall risk video " , " One step at a time, for patient and family to view (Channel 5 or educational VCR video) or handout, " A Guide to Preventing Falls, can also be provided. Reportable Conditions. 1. Report the following to patient ' s physician: a. All falls. b. Development/deterioration of altered mobility. c. Development/deterioration of mental

Based on record reviews and interviews the hospital failed to ensure a Registered Nurse supervised and evaluated the nursing care for each patient as evidenced by: Findings:

1) faiiling to follow hosptital's fall risk protocol for a patient who fell 3 times and was found attempting to climb over the side rails of her bed on numerous occasions with one fall while physician ordered 1:1 observation orders were not being followed. for 1 of 5 sampled patients (#5)

2) failing to maintain patient #4 in Line of Sight (LOS) observation on 3/9/10 and 3/11/10 which resulted in a fall each time LOS was not maintianed and by failing to notify the physician that the patient had hit the back of her head when she fell the first time (3/9/10) and had a change in her mental status from alert to drowsy 40 minutes later and by failing to notify the physician that the patient had hit the back of her head when she fell and had a change in her mental status from alert to drowsy 3 hours after her second fall on 3/11/10 for 1 of 5 sampled focused fall patients. ( #4)

3) failing to maintain patient #2 on one-to-one observation for resulting in a patient fall 5 minutes later for 1 0f 5 sampled patients who fell while one-to-one orders were not being followed. (#2).

4) failing to ensure a high fall risk patient (#3) that required assistance with ambulation did not fall and fracture her tibia/fibula when the staff member walked alongside of the patient, noted the patient had an unsteady gait, then instructed the patient to grab onto the wall railing for 1 of 5 sampled fall patients, (Patient #3)

5) failing to follow hospital policy by not placing an indicator outside the patients room as stipulated in the "Hospital Policy: Falls Protocol" for 9 of 11 randomly sampled patients identified as a high fall risk in a total census of 28 on unit 43.

6) failing to place a yellow arm band on patients identified as a high fall risk as stipulated in the "Hospital Policy: Falls Protocol" for 5 of 10 randomly sampled patients identified as a high fall risk and present on the floor (one patient was off the floor for tests) in a total census of 28 on Unit 43.

7) failing to follow the "Hospital Policy: Falls Protocol" by failing to place an indicator on the medical record that the patient was at high risk for falls for 11 of 11 randomly sampled high fall risk patients in a total census of 28 on Unit 43.

Findings:

1)

Patient #5

Review of the Admission Orders for patient #5 revealed the patient was admitted on 03/18/10 to S28MD with a diagnosis of Altered Mental status and CVA (cerebrovascular accident - stroke). Further orders included: " Physical Therapy and Occupational Therapy: Evaluate and treat " and " Physical Therapy and Occupational Therapy: Evaluate and treat in 24 hours. " Further review of the physician admission orders under " Activity " revealed the physician gave no orders for the activity level of patient #5.

Further review of handwritten Physician Orders dated 03/18/10 at 1930 (7:30 p.m.) revealed: " ...5. Fall Precautions .... "

Review of the nursing notes for 03/18/10 at 1745 (5:45) revealed an admission assessment by S12RN. Review of the assessment revealed the following documentation: " Skin warm and dry. ...no evidence of rashes, lesions or skin breakdown. Ambulation ability - assistive device. Weight bearing ability - Full. Gait pattern - Shuffling. History of falls - No. " The fall risk score for patient #5 was 20. (Fall risk score of 0 - 24 is defined as low risk - basic interventions. 25 - 44 is Moderate risk - standard interventions. and > 44 is High risk - High Risk interventions)

In an interview on 04/14/10 at 9:10 a.m. S12RN confirmed that if she had added the recent history of a fall that this would have raised the Fall Risk Score of patient #5 to 45, in the High Risk for Fall range. S12RN further indicated that 2 staff members attempted to stand patient #5 to move her from the ER stretcher to the bed in the room. S12RN indicated that even with a 2 person assist it was determined that patient #5 was too weak to perform the transfer. Patient #5 was seated back on the ER stretcher and moved to the hospital bed in the room by sliding her over.

In the same interview S12RN confirmed that her 03/18/10 at 1800 (6:00 p.m.) documentation of " Side Rails - Upper Times Two - Lower Times Two " is restraints and she had no physician order for restraints.

Review of the nursing documentation for 03/18/10 night shift by S14RN revealed the following: " 03/18/10 at 1949 (7:49 p.m.) Ambulation ability - Assistive device. Weight Bearing ability - full. Gait pattern - shuffling. Skin Location Modifier: Left. Skin Location Body Site: Knee. Skin Problem: SWELLING. History of Falls - Yes. Fall Risk Screening Score - 45 (high risk).

Further review of nursing documentation for 2040 (8:40 p.m.) read: " Patient was found sitting on floor " I need to get up and go. " Also " You don ' t look like my family. " Reoriented. Helped back into bed. Dr. and daughter notified per Code White Form. No distress noted. Verbally reoriented by house supervisor and nursing staff. However difficult due to patient hard of hearing with some possible short term memory loss. Will continue to monitor. " Documentation for 03/18/10 at 2045 (8:45 p.m.) under " Perform Neuro Check " reads: " S/P (status post) Fall - assessment done. No change in neurological status post fall. Very hard of hearing. "

In an interview on 04/15/10 at 8:20 a.m. with S27RN, Charge Nurse, she confirmed that 4 side rails were up and that this is considered restraints. She further stated that by putting 4 side rails up it makes the patient fall from higher. S27RN confirmed there were no changes made to the care plan of patient #5. S27RN also confirmed there was no documented head to toe assessment documented after the fall of patient #5.

Review of the Meditech Patient Notification (incident report) revealed that patient #5 was " found on floor in patients room. " Nature of injury is documented as " no injury noted. " Fall information is documented as " Fell from: bed. Condition prior to fall: confused. Side Rail Position: 4 up. Was Fall Assessment completed prior to Fall: Y (yes). Was Fall Assessment Completed after Fall: Y. " Documentation entered by S27RN Charge Nurse on 03/18/10 at 2147 (9:47 p.m.) reads as follows: " called to room by nurse (S26RN) patient on floor, states she was trying to go to the bathroom to urinate (has a foley). Reoriented and placed back in bed with 2 person assist. Vitals stable. "

Further review of the document revealed that on 04/12/10 at 8:29 a.m. (the 26th day since the fall of patient and the day of entry on the complaint) S8RN, Unit Director, entered the following: " Patient was a high risk for falls. (review of the admission assessment fall risk revealed patient #5 was documented as having a fall risk score of 20 which is low risk. The initial assessment failed to include the recent history of a fall which would have placed #5 in the high risk for falls category) Patient had soaks (socks) on. Patient was educated not to get out of bed, but was confused. Alone in the room. A Code White was called. "

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/18/10 at 2045 (8:45 p.m.) ....found on floor with all 4 rails up - trying to go to bathroom ....to void (has foley). " There is no changes documented in the plan of care of #5 after each fall or after she is repeatedly found attempting to go over the side rails.

In an interview on 04/14/10 at 2:00 p.m. S8RN, Unit 43 Director, stated that there was no thorough investigation done on the 03/18/10 fall (1st fall) of patient #5. The DON was present for this interview.

Review of the next nursing documentation for 03/18/10 at 2200 by S14RN revealed the following under Neuro Check Comment - " No change in Neurological status post fall. Still needs reorienting which is difficult due to being very hard of hearing. "

Review of the next nursing documentation for 03/18/10 at 2215 by S14RN revealed the following under Rounding comment - " Watching television. Reoriented. Instructed repeatedly to not get out of bed without help. "

Review of the next nursing documentation for 03/18/10 at 2215 by S14RN revealed the following under Rounding comment - " Patient was found by Charge Nurse attempting to crawl over foot of bed. Repositioned back into bed. New bed with alarm found and replaced for patient. Will have nursing closely observe patient at bedside. "

Review of the nursing documentation for 03/19/10 for 0000 (midnight), 0100 (1:00 a.m.), 0200 (2:00 a.m.), and 0300 (3:00 a.m.) all revealed " nurse observing from bedside. "

Review of the nursing documentation by S14RN for 03/19/10 at 0300 (3:00 a.m.) under Rounding comment reads: " Patient pulled out IV. (intravenous catheter) IV restarted per (S27RN, Charge Nurse). Patient repeatedly reoriented. " I still need to get up and go outside " . Will continue to monitor at bedside. "

Review of the nursing documentation by S14RN for 03/19/10 at 0400 (4:00 a.m.) under Rounding comment reads: " Patient (#5) moving off bed. Stopped by nurse at bedside. Continuing to reorient. "

Review of the nursing documentation by S14RN for 03/19/10 at 0500 (5:00 a.m.) under Rounding comment reads: " nursing staff still at bedside. "

S14RN failed to show up for his scheduled interview with the surveyor ' s on 04/15/10. The hospital was not able to reschedule S14RN for interview. The DON stated S14RN was scheduled the previous day to be in this a.m. but he was a no show. Review of the medical record for patient #5 revealed S14RN was the nurse on duty for 2 of 3 of patient #5 ' s falls.

Review of the Physical Therapist documentation for the day shift on 03/19/10 at 1100 (11:00 a.m.) by S19PT revealed the following: " Pt. is a 94 Y/O (year old) admitted after she couldn ' t get up from a fall at home and was found on the floor by a family member. Prior Mobility Status Level - Independent. Prior Activity Level - ADL ' s. (activities of daily living) Prior Living Arrangements - Home Alone. Living Situation Comment - ..Pt. lives alone, daughter ' s check in daily to help with cleaning and cooking. Are you having pain now? Y (yes) Pt. c/o (complain of) L (left) Leg Pain. Nursing Informed of Pain? Y. Face - Occasional Grimace/Frown. Transfers to chair. Transfers from bed. Additional Functional Mobility Assistance Required - Moderate Assist. Assistive Devices - Rolling Walker, Gait Belt. Pt. T/Ferred (transferred) bed to chair with Mod (moderate) assist X2. (two therapist helping) Pt. c/o pain L LE (left lower extremity) with mobilization. Also when calf is squeezed. Nursing notified. Recommend D.C. (discharge) to NH (nursing home) with OT/PT. "

Review of the " Hospitalist Assessment Form " dated/timed 03/19/10 at 12:30 p.m. by S28MD revealed " Gait - non-ambulatory. PT eval still pending. There is no documentation by the physician responsible for the care of patient #5 that she was notified that patient #5 was found on the floor on 03/18/10 at 2040 (8:40 p.m.)

Review of the nursing documentation for 03/19/10 at 1418 (2:18 p.m.) by S40RN, revealed " very weak, unable to put full weight on legs and Left Knee Swelling. "

Review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/19/10 at 1600 (4:00 p.m.) under Rounding Comment that read: " Found with legs over side rails attempting to get out of bed. Encouraged to remain in bed. No signs distress noted. Monitoring. " Further review of the " Shift Physical Assessment " dated/timed 03/19/10 at 2000 (8:00 p.m.) revealed: " Left Knee Swelling. Side Rails up - Upper Times Two - Lower Times Two. " Review of the " Nursing Rounds " dated/timed 03/19/10 at 2000 (8:00 p.m.) revealed: " Side Rails up - Upper Times Two - Lower Times One. " The Fall Risk Score is documented as 45 (high risk) on 03/19/10 at 2000 (8:00 p.m.)

Further review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/20/10 at 0000 (midnight) under Rounding Comment that read: " Found with legs over side rails attempting to get out of bed. Repositioned and pulled up in bed. Encouraged to remain in bed. No signs distress noted. Monitoring. "

Further review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/20/10 at 0315 (3:15 a.m.) under Rounding Comment that read: " Found on floor. States " I was trying to go to the bathroom. Code White protocol initiated. Physician and family notified. No signs of distress noted. 1:1 order noted. Sitter at bedside monitoring. "

Review of physician orders dated/timed 03/20/10 at 0345 (3:45 a.m.) revealed a telephone order from S13MD documented by S14RN that read " 1:1 (one to one observation) and x-ray of L (left) knee and R (right) hip.

In an interview with S13MD, Hospitalist, he stated that the nurse had documented the wrong hip to be x-rayed. S13MD stated he ordered the Left hip to be x-rayed as he would expect blunt force from a fall onto the left knee to be projected to the left hip. S13MD could not explain why he authenticated the same order (without date or time) if it was not correct.

Review of the Fall Risk Assessment dated/timed 03/20/10 at 0338 (3:38 a.m.) revealed patient #5 now had a Fall Risk score of 75.

S14RN failed to show up for his scheduled interview with the surveyor ' s. The hospital was not able to reschedule S14RN for interview.

Review of the Meditech Patient Notification Log revealed there was no incident report filled out for the fall of patient #5 on 03/20/10 at 3:15 a.m.

Review of the Code White form used by the hospital revealed: " Date/Time of Fall: 03/20/10 at 0315 (3:15 a.m.) ...Patient response to event: confused. Staff present at time of fall: No. Risk factors for Fall: Previous fall, confused. Side rails in Use: 4. "

Review of the physician ' s Progress Note documented for 03/20/10 by S28MD, Attending Physician, revealed " fell again 3X (times) she advises -> has 1:1 now. x-ray of hip negative. " There is no documentation that the physician responsible for the care of patient #5 was notified of the L Hip pain of patient #5. (and that the x-ray was done on the R hip)

Review of the nursing documentation for 03/20/10 day shift by S16LPN dated/timed 03/20/10 at 0800 (8:00 a.m.) revealed the following " Left Knee Swelling and Left Hip Bruise. left hip and left knee tender to touch s/p fall. " There is no documentation of notification of the physician responsible for the care of patient #5 of the new assessment findings on the Left Hip. Under " Additional Pain Information " S16LPN documented " no complaints of pain, hurts when left knee or left hip is touched. "

In an interview on 04/12/10 at 2:00 p.m. with S16LPN he stated he could not remember if he was given the assessment findings of left hip bruise/pain in report. He further indicated that if it was a new finding he would notify the physician responsible for the care of the patient.

In an interview on 04/13/10 at 1:50 p.m. with the DON and S8RN, Unit 54 Director, both stated they would expect physician notification of the change in status/assessment of patient #5.

The DON further indicated in an interview on 04/13/10 at 3:00 p.m. that patient #5 was at risk to fall, that she was left alone in the room and that she fell as a result of this.

In an interview on 04/14/10 at 9:20 a.m. with the DON she confirmed that there was no variance/incident report filled out for this fall per hospital policy.

Review of the Fall Risk Assessment dated/timed 03/20/10 at 0800 (8:00 a.m.) revealed patient #5 had a Fall Risk Score of 95.

Review of the nursing documentation for 03/20/10 night shift by S14RN dated/timed 03/20/10 at 2000 (8:00 p.m.) revealed: " bilateral lower extremity push weakness, left knee swelling, left hip bruising. "

Review of the documentation by S14RN dated/timed 03/20/10 at 2000 (8:00 p.m.), 2200 (10:00 p.m.), 0000 (midnight), 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) under Nursing Rounds - Rounding Comment revealed: " Resting in bed. Family at bedside ... ... "

Review of the nursing documentation for 03/21/10 day shift by S15LPN dated/timed 03/21/10 at 0900 (9:00 a.m.) revealed patient #5 had a Fall Risk Score of 75. Review of the nursing documentation for 03/21/10 at 1000 (10:00 a.m.) by S15LPN revealed " Left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Further review of the nursing documentation for 03/21/10 at 1800 (6:00 p.m.) revealed " Bedbath given -
Small skin tear noted on buttocks - placed on pillows. " There is no documentation of notification of the physician responsible for the care of patient #5 of the skin tear..

Review of the physician ' s Progress Note dated 03/21/10 at 10:30 a.m. revealed " Fall - Secondary to generalized weakness. "

Review of the nursing documentation for 03/21/10 night shift by S14RN dated/timed 03/21/10 at 2000 (8:00 p.m.) revealed: " ...No evidence of Rashes, Lesions, or Skin Breakdown. Left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Review of the Fall Risk Assessment dated/timed 03/21/10 at 2000 (8:00 p.m.) revealed patient #5 had a Fall Risk Score of 95.

Review of the nursing documentation for 03/22/10 at 0000 (midnight), 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) revealed " sitter at bedside. "

Review of the PT documentation for 03/22/10 at 1105 (11:05 a.m.) revealed " treatment not performed " and the reason documented is " maintenance working in room. " Further review of the PT documentation for 03/22/10 at 1135 (11:35 a.m.) revealed " treatment not performed " and the reason documented is " Patient Declined. " There is no documentation of notification of the physician responsible for the care of patient #5 that PT was not done as ordered.

Review of physician orders written by S29MD dated/timed 03/22/10 at 1:00 p.m. revealed the physician again ordered " Fall Precautions " .

Review of the physician ' s Progress Note for 03/22/10 (no time indicated) by S13MD, Hospitalist, revealed " s/p fall. Exam: no focal neurological deficit. No evidence of trauma. Vest restraint. "

Review of the nursing documentation for 03/22/10 day shift by S23RN at 1600 (4:00 p.m.) revealed " family at chairside." Pt. sitting up in chair in room. Very confused and not talking clear. Will move Pt. closer to nurses ' station. "

Review of the nursing documentation for 03/22/10 day shift by S40RN revealed documentation timed at 1611 (4:11 p.m.) that read in part: " family at bedside. "

Review of nursing documentation on 03/22/10 at 1800 (6:00 p.m.) by S23RN revealed " move pt. to room 4322 for safety across from nurse ' s station for closer monitoring. "

In an interview on 04/14/10 at 8:50 a.m. with S23RN she stated she moved patient #5 from room 4306 to room 4322 on the evening shift on 03/22/10. She further indicated the move took 5 minutes. S23RN stated she told the family if they left the room to leave the door open and leave light on. S23RN further indicated that patient #5 was found on the floor during shift change. S23RN stated she was aware of the physician ' s order for 1:1 observation for patient #5 and that the physician was not notified the order was not being followed.

Review of the nursing documentation for 03/22/10 night shift by S22LPN at 1900 (7:00 p.m.) revealed the following: " left knee swelling, left hip bruise, left hip and knee tender to touch s/p fall. "

Documentation by S22LPN for 03/22/10 at 1900 (7:00 p.m.) also included the following: " Dr. is on the floor at the time of the Code White and ordered the vest restraints on the pt. This is her 5th time falling in this hospital. 1:1 is ordered by (name). House Supervisor states that they don ' t have the staffing to cover a 1:1. " Documentation for the same date/time by S22LPN under " Medical/Surgical Healing Restraints - Alternative Strategies Attempted " include " Family/Sitter at bedside. " Under " Demonstrated Patient Behavior " S22LPN documented " Climbing Out of Bed/Chair. "

Review of preprinted " Physician Orders Restraints " dated/timed 03/22/10 at 2000 (8:00 p.m.) revealed the following: " 1. Patient is at risk for harm to self and alternatives to restraints exhausted. 2. Apply least restrictive device: Vest Restraint is checked and Left and Right Soft Wrist (restraints) are checked. 3. When patient is no longer at risk for harm to self/others, restraints may be removed early. " Handwritten under this order is " or if 1:1 is in room. " (as ordered by the physician on 03/20/10 at 3:45 a.m.) Further review revealed this was a verbal order taken by S27RN, House Supervisor from S13MD, the same physician who ordered 1:1 supervision for patient #5 on 03/20/10 at 3:45 a.m.

In an interview on 04/14/10 at 10:40 a.m. with S13MD he stated that the " patient (#5) fell due to the staff not following his order for 1:1 observation. " (dated 03/20/10)

Review of the Meditech Patient Notification Form (incident report) revealed an event date of 03/22/10 at 1930 (7:30 p.m.). Location is listed as room 4322. Nature of injury is " No Injury Noted. " Further review revealed the following documentation: " Fell from: bed. Condition prior to fall: confused. Side rail position: 4 up. Was Fall Assessment completed prior to fall? N (no). Was fall assessment completed after fall? Y. " The following documentation was entered by S27RN, Charge Nurse on 03/22/10 at 2000 (8:00 p.m.): " Patient found on floor by bed. States she was trying to go to bathroom. Put back in bed and reoriented. " S8RN, Unit 43 Director documented the following on 03/25/10 at 9:32 a.m.: " Patient was confused alone in room. (the physician had ordered 1:1 supervision on 03/20/10) Family and physician notified of fall. Code White called. Patient has slipper soaks (sp?) and yellow flag used. Patient moved closer to nurse station. (this move from room 4306 to 4322 occurred prior to the patient fall) Patient placed back on a 1:1. No narcotics given. "

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/22/10 at 1930 (7:30 p.m.) ....found on floor ...Medical/nursing actions: back to bed, reoriented ...Staff present at time of fall: No ...Risk factors for fall: disorientation ....Siderails in use: 4. "

In an interview on 04/14/10 at 2:00 p.m. S8RN, Unit 43 Director was asked if there was an investigation into the fall of patient #5 on 03/22/10 (fall #3). She replied she was in the process of performing the investigation. She was asked to provide the documentation to the surveyor ' s. S8RN, Unit 43 Director produced a copy of the 2nd Grievance Report from the family of patient #5 with a few handwritten notes.

Review of the nursing documentation for 03/22/10 at 2200 (10:00 p.m.) by S22LPN under Rounding Comment reads: " Resting in bed. Alone in room. Restraints applied. Pt. has pulled out her IV. Wrist restraints applied. "

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated that no one was in the room per the physician ' s order for 1:1 supervision on the night shift for 03/22/10. S22LPN stated she could not remember if she notified the physician that they were not in compliance with his order for 1:1 supervision of patient #5. S22LPN stated that not following the physician ' s order contributed to the fall of patient #5 on 03/22/10. The DON and Director of Unit 43 were present for this interview.

Review of the physician ' s Progress Note dated 03/23/10 at 11:15 a.m. by S13MD, Hospitalist, revealed " pt fell last night. No injury.

Review of the nursing documentation for 03/23/10 day shift by S23RN dated/timed 03/23/10 at 0800 (8:00 a.m.) reads in part: " left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Further review of the documentation by S23RN for 03/23/10 at 0800 (8:00 a.m.) under Rounding Comments revealed: " Awake. Alert. Oriented to person, and confused. ... ...Bil. (bilateral) wrist restraints intact. Pt. pulls out all tubing and climbs out of bed per self and unable to walk. 1:1 supervision in room with pt. Daughter at bedside. Pt. pulling off 02 at this time. Nurse placed it back. "

Review of a PT note for 03/23/10 at 1330 (1:30 p.m.) by S21PTA revealed under daily note comment: " after removing wrist restraints and attempting to sit EOB (edge of bed) Pt became combative. Pt hitting and digging with fingernails. Unable to secure wrist restraints. Notified sitter and she will watch Pt until restraints can be reapplied. "

In an interview on 04/13/10 at 1:40 p.m. with the DON she confirmed that neither the PTA nor the sitter in the room with patient #5 had training to apply or remove restraints.

Review of the documentation by S23RN for 03/23/10 at 1530 (3:30 p.m.) under Nursing Rounds - Rounding Comment read: " assist to chair in bedroom. Daughter and 1:1 sitter at bedside. Wrist restraints off at this time. " Under Additional restraint Information documented on 03/23/10 at 1530 (3:30 p.m.) S23RN documented " Verbal contract with Pt. and Daughter to have Pt. sit in chair without restraints at this time. With also 1:1 sitter at bedside to monitor pulling of tubes and attempting to get up. "

Review of the nursing documentation for 03/23/10 night shift by S22LPN revealed documentation for 03/23/10 at 1900 (7:00 p.m.) that read in part: " left knee swelling, left hip bruise, resting in bed, 1:1 in room ... " Further review of the documentation by S22LPN on 03/23/10 at 2200 (10:00 p.m.), 0000 (midnight), 03/24/10 at 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) revealed 1:1 in room.

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated she could not remember if she notified the physician responsible for the care of patient #5 of the left hip bruise/pain. S22LPN further indicated that there was 1:1 supervision in the room of patient #5 on the night of 03/23/10 and that patient #5 had no falls that night. S22LPN further stated that 1:1 supervision was effective in keeping patient #5 from falling.

Review of the nursing documentation for 03/24/10 day shift by S24LPN dated/timed 03/24/10 at 0800 (8:00 a.m.) read in part: " left knee swelling, left hip bruise. "

Review of the Discharge Education for Patient documented on 03/24/10 at 0905 (9:05 a.m.) revealed under Additional Activity Limitation Instructions " Fall Precaution. " Patient #5 was discharged to NH " a " .

In an interview on 04/14/10 at 2:30 p.m. with S24LPN she confirmed her documentation of left hip bruised. S24LPN further indicated she did not remember the patient (#5) of if she notified the physician responsible for the care of the patient of the bruise.

Review of the Discharge Summary with a DD (date dictated) of 03/23/2010 (no time indicated) by S29MD revealed the following: " FINAL DIAGNOSES: 1. Altered mental status secondary to dementia....3. Rhabdomyolosis, resolved........5. Hypertension, stable. 6. Hypokalemia, resolved. 7. Severe pulmonary hypertension ...HOSPITAL COURSE: This is a 94 year old female with significant past history of hypertension. The patient was brought in by a family member due to altered mental status and a fall ... ...The patient is awake but oriented to people and place. The patient had overall weakness due to the age of 94. The patient otherwise was in a relatively stable condition. The patient had a fall last night but did not sustain any injury or fracture ....DISPOSITION: She (patient #5) will be discharged to Nursing Home tomorrow morning around 10 a.m. .....Activity will be as tolerated. Fall precautions. The patient needs close monitoring due to dementia ... "

Review of a hospital policy titled " One to One Guidelines " , policy number NR-1-2-20, issued 07/23/08, last revised 09/24/08, presented as current hospital policy, reads in part: " Purpose: The use of one-to-one sitters has become a common alternative to the application of restraints and to provide a care environment of increased safety. One-to-One usage has been used for patients at risk for disrupting therapy and those at risk for falls without evidence of improved outcomes from alternative actions. NOTE: physical restraint will be used as a last resort for patient safety. Potential Reasons for One-to-One usage: ... ...Fall since admission with risk of another fall .....Standard of Care. The patient/care giver can expect the patient will be provided a safe care environment. Procedure/Process. A. One-to-One Use Decision-Making Process: 1. Patient exhibits ...fall risk, post fall. Nursing Staff institutes alternatives to one-to-one ....(C. Alternatives for ...fall risk: 1. Family asked to stay with patient. 2. Patient moved closer to nurses ' station. 3. Use of bed with bed alarm. 4. Clinical review of necessity of medical devices ...possibly discontinue device/line ....7. Pain management - comfort measures. 8. Address possible hunger .....10. Medication to reduce anxiety. 11. Increased frequency of staffing rounds. 12. Toileting schedule ... ...16. Patient load reduced for primary nurse of this patient- allows more time to be spent with this patient. 17. Team nursing approach - Staff taking turns charting in patients room. 18. Use of restraints. (Last resort)) ....2. Assessment of effectiveness of alternatives ...NO - RN completes one-to-one justification form. 3. RN contacts Nursing Director or House Supervisor and reviews ... ...approval? Yes - One-to-One used ....When a One -to _one order is written the nurse will collaborate with the physician to discuss other alternatives if indicated. If the physician does not feel comfortable with alternatives presented, the order for 1:1 will be followed.

Review of a hospital policy titled " Patient Falls Prevention " , policy number TX-A-480, issued 07/91, last revised 10/08, presented as current hospital policy, reads in part: " Standard of Care. The patient/caregiver can expect to have adequate precautions taken to prevent harm to patients at high risk for falls. Standard of Practice. The nursing staff will assess all patients, identify those who are high-risk for falls and implement precautions to prevent harm/injury. Procedure. I. The nurse will assess the patients at risk for falls: A. High-risk patient (includes but not limited to one or more of the following): over 70 years of age; confused and disoriented, hallucinations; altered mental status; recent history of falls; chronic disease; recent history of loss of consciousness, seizures; unsteady on feet, syncope; poor general health; sensory deficits; ...drugs (i.e., anti-hypertensive ...); ....decreased mobility. II. The nurse will assess the patient for fall risk on admission and daily during the hospital stay or more frequently if indicated by a change in patient status. Patients at high risk for falls will be identified by a neon yellow band to be placed on the same limb as the patient identification bracelet. III. The nursing staff will check a " high risk " patient every two hours and document nursing interventions in the ongoing assessment ...Safety Interventions. Keep call bell/light within patient ' s reach at all times and assure that the patient is able to use it ....Assist patient with transfers/ambulation as needed ....Keep night light on during evening/night hours. Patient/Family Instruction. 1. Provide " fall risk video " , " One step at a time, for patient and family to view (Channel 5 or educational VCR video) or handout, " A Guide to Preventing Falls, can also be provided. Reportable Conditions. 1. Report the following to patient ' s physician: a. All falls. b. Development/deterioration of altered mobility. c. Development/deterioration of mental status. (confusion, disorientation/hallucinations) d. Deterioration in level of consciousness (LOC). e. Change in behavior .....f. Sensory impairment. Documentation. 1. Record Fall Risk Assessment Score daily under the ongoing Review of Systems. 2. In the event a patient does fall: reassess the patient; Document in the medical record the facts as they pertain to the situation; Document the assessment of the condition of the patient following the fall and any actions taken as a result of the fall; Identify and document the reason for the fall; Complete an online patient notification in Meditech; Notify the Unit Manager or House Supervisor and Risk Management .....Noti

Based on record review and interview the hospital failed to ensure the nursing care plan based on assessed patients needs had been implemented, revised according to changes in patient condition and monitored for effectiveness for 2 of 5 (#5, #4) sampled patients by failing to revise the plan of care and implement fall precautions which resulted in the patient falling again and sustaining injury. Findings:


Patient #5

Review of the Admission Orders for patient #5 revealed the patient was admitted on 03/18/10 to S28MD with a diagnosis of Altered Mental status and CVA (cerebrovascular accident - stroke). Further orders included: " Physical Therapy and Occupational Therapy: Evaluate and treat and Physical Therapy and Occupational Therapy: Evaluate and treat in 24 hours." Further review of the physician admission orders under "Activity" revealed the physician gave no orders for the activity level of patient #5.

Further review of handwritten Physician Orders dated 03/18/10 at 1930 (7:30 p.m.) revealed: " ...5. Fall Precautions .... "

Review of the nursing notes for 03/18/10 at 1745 (5:45 p.m.) revealed an admission assessment had been performed by S12RN with the following documentation: "Skin warm and dry. ...no evidence of rashes, lesions or skin breakdown. Ambulation ability - assistive device. Weight bearing ability - Full. Gait pattern - Shuffling. History of falls - No." The fall risk score for patient #5 was assessed as 20. (Fall risk score of 0 - 24 is defined as low risk - basic interventions. 25 - 44 is Moderate risk - standard interventions. and > 44 is High Risk - High Risk interventions).

In an interview on 04/14/10 at 9:10 a.m. S12RN confirmed that if she had added the recent history of a fall that this would have raised the Fall Risk Score of patient #5 to 45, in the High Risk for Fall range. S12RN further indicated that 2 staff members attempted to stand patient #5 to move her from the ER stretcher to the bed in the room. S12RN indicated that even with a 2 person assist it was determined that patient #5 was too weak to perform the transfer. Patient #5 was seated back on the ER stretcher and moved to the hospital bed in the room by sliding her over.

In the same interview S12RN confirmed that her 03/18/10 at 1800 (6:00 p.m.) documentation of " Side Rails - Upper Times Two - Lower Times Two " is restraints and she had no physician order for restraints.

Review of the Care Plan for patient #5 revealed the patient was care planned for "Use Three Bedrails."

Review of the nursing documentation for 03/18/10 night shift by S14RN revealed the following: " 03/18/10 at 1949 (7:49 p.m.) Ambulation ability - Assistive device. Weight Bearing ability - full. Gait pattern - shuffling. Skin Location Modifier: Left. Skin Location Body Site: Knee. Skin Problem: SWELLING. History of Falls - Yes. Fall Risk Screening Score - 45 (high risk).

Further review of nursing documentation for 2040 (8:40 p.m.) read: " Patient was found sitting on floor " I need to get up and go. " Also " You don ' t look like my family. " Reoriented. Helped back into bed. Dr. and daughter notified per Code White Form. No distress noted. Verbally reoriented by house supervisor and nursing staff. However difficult due to patient hard of hearing with some possible short term memory loss. Will continue to monitor. " Documentation for 03/18/10 at 2045 (8:45 p.m.) under " Perform Neuro Check " reads: " S/P (status post) Fall - assessment done. No change in neurological status post fall. Very hard of hearing. "

In an interview on 04/15/10 at 8:20 a.m. with S27RN, Charge Nurse, she confirmed that 4 side rails were up and that this is considered restraints. She further stated that by putting 4 side rails up it makes the patient fall from higher. S27RN confirmed there were no changes made to the care plan of patient #5. S27RN also confirmed there was no documented head to toe assessment documented after the fall of patient #5.

Review of the Meditech Patient Notification (incident report) revealed that patient #5 was " found on floor in patients room. " Nature of injury is documented as " no injury noted. " Fall information is documented as " Fell from: bed. Condition prior to fall: confused. Side Rail Position: 4 up. Was Fall Assessment completed prior to Fall: Y (yes). Was Fall Assessment Completed after Fall: Y. " Documentation entered by S27RN Charge Nurse on 03/18/10 at 2147 (9:47 p.m.) reads as follows: " called to room by nurse (S26RN) patient on floor, states she was trying to go to the bathroom to urinate (has a foley). Reoriented and placed back in bed with 2 person assist. Vitals stable. "

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/18/10 at 2045 (8:45 p.m.) ....found on floor with all 4 rails up - trying to go to bathroom ....to void (has foley). " There is no changes documented in the plan of care of #5 after each fall or after she is repeatedly found attempting to go over the side rails.

Further review of the document revealed that on 04/12/10 at 8:29 a.m. (the 26th day since the fall of patient and the day of entry on the complaint) S8RN, Unit Director, entered the following: " Patient was a high risk for falls. (review of the admission assessment fall risk revealed patient #5 was documented as having a fall risk score of 20 which is low risk. The initial assessment failed to include the recent history of a fall which would have placed #5 in the high risk for falls category) Patient had soaks (socks) on. Patient was educated not to get out of bed, but was confused. Alone in the room. A Code White was called. "

In an interview on 04/14/10 at 2:00 p.m. S8RN, Unit 43 Director, stated that there was no thorough investigation done on the 03/18/10 fall (1st fall) of patient #5. The DON was present for this interview.

Review of the next nursing documentation for 03/18/10 at 2200 by S14RN revealed the following under Neuro Check Comment - " No change in Neurological status post fall. Still needs reorienting which is difficult due to being very hard of hearing. "

Review of the next nursing documentation for 03/18/10 at 2215 by S14RN revealed the following under Rounding comment - " Watching television. Reoriented. Instructed repeatedly to not get out of bed without help. "

Review of the next nursing documentation for 03/18/10 at 2215 by S14RN revealed the following under Rounding comment - " Patient was found by Charge Nurse attempting to crawl over foot of bed. Repositioned back into bed. New bed with alarm found and replaced for patient. Will have nursing closely observe patient at bedside. "

Review of the Care Plan for patient #5 created on 03/18/10 at 1910 (7:10 p.m.) by S27RN, Charge Nurse, revealed the patient's care plan included "Use bed/chair alarms." The bed alarm was not put into use until patient #5 had fallen once and was found attempting to go over the side rails by S27RN, Charge Nurse.

Review of the nursing documentation for 03/19/10 for 0000 (midnight), 0100 (1:00 a.m.), 0200 (2:00 a.m.), and 0300 (3:00 a.m.) all revealed " nurse observing from bedside. "

Review of the nursing documentation by S14RN for 03/19/10 at 0300 (3:00 a.m.) under Rounding comment reads: " Patient pulled out IV. (intravenous catheter) IV restarted per (S27RN, Charge Nurse). Patient repeatedly reoriented. " I still need to get up and go outside " . Will continue to monitor at bedside. "

Review of the nursing documentation by S14RN for 03/19/10 at 0400 (4:00 a.m.) under Rounding comment reads: " Patient (#5) moving off bed. Stopped by nurse at bedside. Continuing to reorient. "

Review of the nursing documentation by S14RN for 03/19/10 at 0500 (5:00 a.m.) under Rounding comment reads: " nursing staff still at bedside. "

S14RN failed to show up for his scheduled interview with the surveyor ' s on 04/15/10. The hospital was not able to reschedule S14RN for interview. The DON stated S14RN was scheduled the previous day to be in this a.m. but he was a no show. Review of the medical record for patient #5 revealed S14RN was the nurse on duty for 2 of 3 of patient #5 ' s falls.

Review of the "Hospitalist Assessment Form " dated/timed 03/19/10 at 12:30 p.m. by S28MD revealed " Gait - non-ambulatory. PT eval still pending. There is no documentation by the physician responsible for the care of patient #5 that she was notified that patient #5 was found on the floor on 03/18/10 at 2040 (8:40 p.m.).

Review of the nursing documentation for 03/19/10 at 1418 (2:18 p.m.) by S40RN, revealed " very weak, unable to put full weight on legs and Left Knee Swelling. "

Review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/19/10 at 1600 (4:00 p.m.) under Rounding Comment that read: " Found with legs over side rails attempting to get out of bed. Encouraged to remain in bed. No signs distress noted. Monitoring. " Further review of the " Shift Physical Assessment " dated/timed 03/19/10 at 2000 (8:00 p.m.) revealed: " Left Knee Swelling. Side Rails up - Upper Times Two - Lower Times Two. " Review of the " Nursing Rounds " dated/timed 03/19/10 at 2000 (8:00 p.m.) revealed: " Side Rails up - Upper Times Two - Lower Times One. " The Fall Risk Score is documented as 45 (high risk) on 03/19/10 at 2000 (8:00 p.m.)

Further review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/20/10 at 0000 (midnight) under Rounding Comment that read: " Found with legs over side rails attempting to get out of bed. Repositioned and pulled up in bed. Encouraged to remain in bed. No signs distress noted. Monitoring. "

Further review of the nursing documentation for 03/19/10 evening/night shift revealed documentation by S14RN dated/timed 03/20/10 at 0315 (3:15 a.m.) under Rounding Comment that read: " Found on floor. States " I was trying to go to the bathroom. Code White protocol initiated. Physician and family notified. No signs of distress noted. 1:1 order noted. Sitter at bedside monitoring. "

Review of physician orders dated/timed 03/20/10 at 0345 (3:45 a.m.) revealed a telephone order from S13MD documented by S14RN that read " 1:1 (one to one observation) and x-ray of L (left) knee and R (right) hip.

In an interview with S13MD, Hospitalist, he stated that the nurse had documented the wrong hip to be x-rayed. S13MD stated he ordered the Left hip to be x-rayed as he would expect blunt force from a fall onto the left knee to be projected to the left hip. S13MD could not explain why he authenticated the same order (without date or time) if it was not correct.

Review of the Fall Risk Assessment dated/timed 03/20/10 at 0338 (3:38 a.m.) revealed patient #5 now had a Fall Risk score of 75.

S14RN failed to show up for his scheduled interview with the surveyor ' s. The hospital was not able to reschedule S14RN for interview.

Review of the Meditech Patient Notification Log revealed there was no incident report filled out for the fall of patient #5 on 03/20/10 at 3:15 a.m.

Review of the Code White form used by the hospital revealed: " Date/Time of Fall: 03/20/10 at 0315 (3:15 a.m.) ...Patient response to event: confused. Staff present at time of fall: No. Risk factors for Fall: Previous fall, confused. Side rails in Use: 4. "

Review of the physician ' s Progress Note documented for 03/20/10 by S28MD, Attending Physician, revealed " fell again 3X (times) she advises -> has 1:1 now. x-ray of hip negative. " There is no documentation that the physician responsible for the care of patient #5 was notified of the L Hip pain of patient #5. (and that the x-ray was done on the R hip)

Review of the nursing documentation for 03/20/10 day shift by S16LPN dated/timed 03/20/10 at 0800 (8:00 a.m.) revealed the following " Left Knee Swelling and Left Hip Bruise. left hip and left knee tender to touch s/p fall. " There is no documentation of notification of the physician responsible for the care of patient #5 of the new assessment findings on the Left Hip. Under " Additional Pain Information " S16LPN documented " no complaints of pain, hurts when left knee or left hip is touched. "

In an interview on 04/12/10 at 2:00 p.m. with S16LPN he stated he could not remember if he was given the assessment findings of left hip bruise/pain in report. He further indicated that if it was a new finding he would notify the physician responsible for the care of the patient.

In an interview on 04/13/10 at 1:50 p.m. with the DON and S8RN, Unit 54 Director, both stated they would expect physician notification of the change in status/assessment of patient #5.

The DON further indicated in an interview on 04/13/10 at 3:00 p.m. that patient #5 was at risk to fall, that she was left alone in the room and that she fell as a result of this.

In an interview on 04/14/10 at 9:20 a.m. with the DON she confirmed that there was no variance/incident report filled out for this fall per hospital policy.

Review of the Fall Risk Assessment dated/timed 03/20/10 at 0800 (8:00 a.m.) revealed patient #5 had a Fall Risk Score of 95.

Review of the nursing documentation for 03/20/10 night shift by S14RN dated/timed 03/20/10 at 2000 (8:00 p.m.) revealed: " bilateral lower extremity push weakness, left knee swelling, left hip bruising. "

Review of the documentation by S14RN dated/timed 03/20/10 at 2000 (8:00 p.m.), 2200 (10:00 p.m.), 0000 (midnight), 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) under Nursing Rounds - Rounding Comment revealed: " Resting in bed. Family at bedside ... ... "

Review of the nursing documentation for 03/21/10 day shift by S15LPN dated/timed 03/21/10 at 0900 (9:00 a.m.) revealed patient #5 had a Fall Risk Score of 75. Review of the nursing documentation for 03/21/10 at 1000 (10:00 a.m.) by S15LPN revealed " Left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Further review of the nursing documentation for 03/21/10 at 1800 (6:00 p.m.) revealed " Bedbath given - Small skin tear noted on buttocks - placed on pillows. " There is no documentation of notification of the physician responsible for the care of patient #5 of the skin tear..

Review of the physician ' s Progress Note dated 03/21/10 at 10:30 a.m. revealed " Fall - Secondary to generalized weakness. "

Review of the nursing documentation for 03/21/10 night shift by S14RN dated/timed 03/21/10 at 2000 (8:00 p.m.) revealed: " ...No evidence of Rashes, Lesions, or Skin Breakdown. Left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Review of the Fall Risk Assessment dated/timed 03/21/10 at 2000 (8:00 p.m.) revealed patient #5 had a Fall Risk Score of 95.

Review of the nursing documentation for 03/22/10 at 0000 (midnight), 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) revealed " sitter at bedside. "

Review of the PT documentation for 03/22/10 at 1105 (11:05 a.m.) revealed " treatment not performed " and the reason documented is " maintenance working in room. " Further review of the PT documentation for 03/22/10 at 1135 (11:35 a.m.) revealed " treatment not performed " and the reason documented is " Patient Declined. " There is no documentation of notification of the physician responsible for the care of patient #5 that PT was not done as ordered.

Review of physician orders written by S29MD dated/timed 03/22/10 at 1:00 p.m. revealed the physician again ordered " Fall Precautions " .

Review of the physician ' s Progress Note for 03/22/10 (no time indicated) by S13MD, Hospitalist, revealed " s/p fall. Exam: no focal neurological deficit. No evidence of trauma. Vest restraint. "

Review of the nursing documentation for 03/22/10 day shift by S23RN at 1600 (4:00 p.m.) revealed " family at chairside." Pt. sitting up in chair in room. Very confused and not talking clear. Will move Pt. closer to nurses ' station. "

Review of the nursing documentation for 03/22/10 day shift by S40RN revealed documentation timed at 1611 (4:11 p.m.) that read in part: " family at bedside. "

Review of nursing documentation on 03/22/10 at 1800 (6:00 p.m.) by S23RN revealed " move pt. to room 4322 for safety across from nurse ' s station for closer monitoring. "

In an interview on 04/14/10 at 8:50 a.m. with S23RN she stated she moved patient #5 from room 4306 to room 4322 on the evening shift on 03/22/10. She further indicated the move took 5 minutes. S23RN stated she told the family if they left the room to leave the door open and leave light on. S23RN further indicated that patient #5 was found on the floor during shift change. S23RN stated she was aware of the physician ' s order for 1:1 observation for patient #5 and that the physician was not notified the order was not being followed.

Review of the nursing documentation for 03/22/10 night shift by S22LPN at 1900 (7:00 p.m.) revealed the following: " left knee swelling, left hip bruise, left hip and knee tender to touch s/p fall. "

Documentation by S22LPN for 03/22/10 at 1900 (7:00 p.m.) also included the following: " Dr. is on the floor at the time of the Code White and ordered the vest restraints on the pt. This is her 5th time falling in this hospital. 1:1 is ordered by (name). House Supervisor states that they don ' t have the staffing to cover a 1:1. " Documentation for the same date/time by S22LPN under " Medical/Surgical Healing Restraints - Alternative Strategies Attempted " include " Family/Sitter at bedside. " Under " Demonstrated Patient Behavior " S22LPN documented " Climbing Out of Bed/Chair. "

Review of preprinted " Physician Orders Restraints " dated/timed 03/22/10 at 2000 (8:00 p.m.) revealed the following: " 1. Patient is at risk for harm to self and alternatives to restraints exhausted. 2. Apply least restrictive device: Vest Restraint is checked and Left and Right Soft Wrist (restraints) are checked. 3. When patient is no longer at risk for harm to self/others, restraints may be removed early. " Handwritten under this order is " or if 1:1 is in room. " (as ordered by the physician on 03/20/10 at 3:45 a.m.) Further review revealed this was a verbal order taken by S27RN, House Supervisor from S13MD, the same physician who ordered 1:1 supervision for patient #5 on 03/20/10 at 3:45 a.m.

In an interview on 04/14/10 at 10:40 a.m. with S13MD he stated that the " patient (#5) fell due to the staff not following his order for 1:1 observation. " (dated 03/20/10)

Review of the Meditech Patient Notification Form (incident report) revealed an event date of 03/22/10 at 1930 (7:30 p.m.). Location is listed as room 4322. Nature of injury is " No Injury Noted. " Further review revealed the following documentation: " Fell from: bed. Condition prior to fall: confused. Side rail position: 4 up. Was Fall Assessment completed prior to fall? N (no). Was fall assessment completed after fall? Y. " The following documentation was entered by S27RN, Charge Nurse on 03/22/10 at 2000 (8:00 p.m.): " Patient found on floor by bed. States she was trying to go to bathroom. Put back in bed and reoriented. " S8RN, Unit 43 Director documented the following on 03/25/10 at 9:32 a.m.: " Patient was confused alone in room. (the physician had ordered 1:1 supervision on 03/20/10) Family and physician notified of fall. Code White called. Patient has slipper soaks (sp?) and yellow flag used. Patient moved closer to nurse station. (this move from room 4306 to 4322 occurred prior to the patient fall) Patient placed back on a 1:1. No narcotics given. "

Review of the Code White form used by the hospital revealed the following: " Date/time of Fall: 03/22/10 at 1930 (7:30 p.m.) ....found on floor ...Medical/nursing actions: back to bed, reoriented ...Staff present at time of fall: No ...Risk factors for fall: disorientation ....Siderails in use: 4. "

In an interview on 04/14/10 at 2:00 p.m. S8RN, Unit 43 Director was asked if there was an investigation into the fall of patient #5 on 03/22/10 (fall #3). She replied she was in the process of performing the investigation. She was asked to provide the documentation to the surveyor ' s. S8RN, Unit 43 Director produced a copy of the 2nd Grievance Report from the family of patient #5 with a few handwritten notes.

Review of the nursing documentation for 03/22/10 at 2200 (10:00 p.m.) by S22LPN under Rounding Comment reads: " Resting in bed. Alone in room. Restraints applied. Pt. has pulled out her IV. Wrist restraints applied. "

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated that no one was in the room per the physician ' s order for 1:1 supervision on the night shift for 03/22/10. S22LPN stated she could not remember if she notified the physician that they were not in compliance with his order for 1:1 supervision of patient #5. S22LPN stated that not following the physician ' s order contributed to the fall of patient #5 on 03/22/10. The DON and Director of Unit 43 were present for this interview.

Review of the physician ' s Progress Note dated 03/23/10 at 11:15 a.m. by S13MD, Hospitalist, revealed " pt fell last night. No injury.

Review of the nursing documentation for 03/23/10 day shift by S23RN dated/timed 03/23/10 at 0800 (8:00 a.m.) reads in part: " left knee swelling, left hip bruise, left hip and left knee tender to touch s/p fall. "

Further review of the documentation by S23RN for 03/23/10 at 0800 (8:00 a.m.) under Rounding Comments revealed: " Awake. Alert. Oriented to person, and confused. ... ...Bil. (bilateral) wrist restraints intact. Pt. pulls out all tubing and climbs out of bed per self and unable to walk. 1:1 supervision in room with pt. Daughter at bedside. Pt. pulling off 02 at this time. Nurse placed it back. "

Review of a PT note for 03/23/10 at 1330 (1:30 p.m.) by S21PTA revealed under daily note comment: " after removing wrist restraints and attempting to sit EOB (edge of bed) Pt became combative. Pt hitting and digging with fingernails. Unable to secure wrist restraints. Notified sitter and she will watch Pt until restraints can be reapplied. "

In an interview on 04/13/10 at 1:40 p.m. with the DON she confirmed that neither the PTA nor the sitter in the room with patient #5 had training to apply or remove restraints.

Review of the documentation by S23RN for 03/23/10 at 1530 (3:30 p.m.) under Nursing Rounds - Rounding Comment read: " assist to chair in bedroom. Daughter and 1:1 sitter at bedside. Wrist restraints off at this time. " Under Additional restraint Information documented on 03/23/10 at 1530 (3:30 p.m.) S23RN documented " Verbal contract with Pt. and Daughter to have Pt. sit in chair without restraints at this time. With also 1:1 sitter at bedside to monitor pulling of tubes and attempting to get up. "

Review of the nursing documentation for 03/23/10 night shift by S22LPN revealed documentation for 03/23/10 at 1900 (7:00 p.m.) that read in part: " left knee swelling, left hip bruise, resting in bed, 1:1 in room ... " Further review of the documentation by S22LPN on 03/23/10 at 2200 (10:00 p.m.), 0000 (midnight), 03/24/10 at 0200 (2:00 a.m.), 0400 (4:00 a.m.) and 0600 (6:00 a.m.) revealed 1:1 in room.

In an interview on 04/17/10 at 8:15 a.m. with S22LPN she stated she could not remember if she notified the physician responsible for the care of patient #5 of the left hip bruise/pain. S22LPN further indicated that there was 1:1 supervision in the room of patient #5 on the night of 03/23/10 and that patient #5 had no falls that night. S22LPN further stated that 1:1 supervision was effective in keeping patient #5 from falling.

Review of the nursing documentation for 03/24/10 day shift by S24LPN dated/timed 03/24/10 at 0800 (8:00 a.m.) read in part: " left knee swelling, left hip bruise. "

Review of the Discharge Education for Patient documented on 03/24/10 at 0905 (9:05 a.m.) revealed under Additional Activity Limitation Instructions " Fall Precaution. " Patient #5 was discharged to NH " a " .

In an interview on 04/14/10 at 2:30 p.m. with S24LPN she confirmed her documentation of left hip bruised. S24LPN further indicated she did not remember the patient (#5) of if she notified the physician responsible for the care of the patient of the bruise.

Review of the entire medical record for patient #5 revealed the patient was never care planned for restraint use (physical or siderails) or for one-to-one supervision.

In an interview on 04/14/10 at 9:20 a.m. with S2DON and S6RN, Unit 43 Director, both were asked to provide any information that may be in the computerized nursing notes that would indicate that changes were made to the plan of care for patient #5 in regards to her falls and attempts to go over the side rails. No further documentation was provided prior to exit on 04/19/10.


Patient #4:

The medical record for Patient #4 was reviewed. #4 was admitted to Unit 54 on 3/2/10 with the admitting diagnosis of Bipolar. Further review revealed #4 had Altered memory/thinking, Oriented to self only, Bilateral weakness to all extremities, Staggering gait pattern, Required required total assistance with positioning/activity in chair, Chairfast-must be assisted into chair or wheelchair, Wheelchair bound with maximum assistance from 3/8/10 to 3/9/10. On 3/9/10 at 9:03 p.m. (2103), #4 was line of sight, total assistance with positioning/activity in chair and confused with disorganized thoughts. At 10:20 p.m. (2220), #4 was "Alert" and found sitting in room on floor (patient fell) after the tech (S32MHT, Unit 54 ) left the patient in the room to get linen. At (11:30 p.m.) 2300, #4 was "Drowsy"-one hour and about 40 minutes after she fell. There was no documented evidence in the record the physician (S28) was notified of #4's change in condition at 11:30 p.m.. On 3/11/10 at 12:00 a.m. (0000), "...Heard pt fall... same area struck yesterday (3/9/10 at 10:20 p.m.)...". At 12:25 a.m. (0025), #4 was "Awake" then "Drowsy" at 3:00 a.m. (0300)- about 3 hours after she fell and hit her head. There was no documented evidence the physician (S28) was notified of #4's change in condition from alert to drowsy from 12:25 a.m. to 3:00 a.m. by S33RN, Unit 54.

Further review of #4's medical record revealed #4 had a 95- Fall Risk Screening Score. For Scores of 45 and greater, all basic, standard, and high fall prevention interventions were to be implemented as follows:
...Bedside Table within reach,
....Call light within reach,
...Room well lit,
...Room free of clutter,
...Equipment wheels locked,
...Bed at lowest position,
...Medication Instruction,
...Bed wheels locked,
...Non-slip footwear,
...No floor length clothing.
...Yellow Arm Band Applied,
...Environmental Screen,
...Hourly rounds,
...Medication review,
...Assisted when walking,
...Mobility aid next to bed,
...Instruct OOB (out of bed) with assistance.

Review of the Incident Report recorded on Patient #4's event occurred on 3/9/10 at 9:55 p.m. (2155)--the Nurse Round notes documented for the same event were timed 10:20 p.m. (2220)-25 minutes later read, "...Pt (patient) was found on the floor up against the wall by the door in her room..." Patient #4 was confused prior to the fall. Further review revealed S37RNCN, Unit 54 recorded "...Heard a loud noise come from the patient's room...the patient was on the floor, sitting near the wall up against a wheelchair...Moved her to a closer vicinity of the nurses' station...". S7Director, Unit 54 documented "...Nurse (S37RNCN, Unit 54 named) notified me of incident. Stated MHT (S32, Unit 54) had rolled patient into room and left patient unattended and patient fell out of her wheelchair. MHT (S32) had no explanation of why he left patient unattended in her room when she clearly had a yellow band on and ws (was) not ambulatory, but very impulsive. Talked with MHT (S32) 1:1 and also informed Charge Nurse (S37) that a code white should have been called, she stated that once she seen the patient on the floor, her first instinct was to help the patient along with the other staff. Processed with her the proedure (procedure) of calling code white...".

There was no Incident Report written for Patient #4's fall on 3/11/10 at 12:00 a.m. (0000).

The Preliminary Radiology Report With Addendum written by S38Radiologist on 3/11/10 at 3:04:08 AM Central for Patient #4 read, "CT BRAIN/HEAD, FALL-HIT OCCIPITAL REGION OF HEAD. LAC (laceration) TO OCCIPITAL REGION...Addendum created by (S38Radiologist's name) on 3/11/2010 3:04:08 AM (S28MD's name) is to be notified by S33RN, (Unit 54), who received the report as of 2:58 a.m. Central. Initial report created on 3/11/2010 2:51:14 AM Clinical information: FALL-HIT OCCIPITAL REGION OF HEAD. LAC (laceration) TO OCCIPITAL REGION. No prior study is available for comparison. Swelling / hematoma in the high posterior scalp. Left frontal-temporal subdural fluid of about 18 HUs of up to 6 mm in width. Midline shift of 4 mm toward the right...".

During an interview with S7Director, Unit 54 and S2DON on 4/14/10 from 12:50 p.m. to 1:30 p.m.. Patient #4's medical record was reviewed by both S7 and S2. S7Director verified Patient #4 was to be in line of site of staff at all times on 3/9/10 at 9:03 p.m. (2103) and required maximum (total) assistance with positioning/activity. S7 indicated #4 fell on 3/9/10 at 10:20 p.m. (2220). She verified the "...Pt (was) found sitting in room on (the) floor...(the) tech left (the) room to get linen..." S7 and S2 both agreed Patient #4 was not in the nursing staff, nor tech's (S32MHT's, Unit 54) line of site when she was found sitting in the room alone with no staff present. S7 reviewed #4's level of consciousness documented at 10:20 p.m. "Alert" and "Drowsy"at 11:30 p.m. - one hour and about 40 minutes after #4 fell. She confirmed there was no documented evidence in the record the physician (S28) was notified of #4's change in condition from alert (10:20 p.m.) to drowsy (11:30 p.m.). S7 indicated the physician (S28) should had been notified of #4's change in condition from alert to drowsy. S7 reviewed S37RNCN, UNIT 54's notes on the Incident Report recorded on 3/10/10 at 7:40 am, "...Heard a loud noise come from the patient's room...the patient was on the floor, sitting near the wall up against a wheelchair...Moved her to a closer vicinity of the nurses' station...". S7 and S2 both agreed "Heard a loud noise come from #4's room and #4 sitting on the floor" meant Patient #4 was not in the staff's line of site at all times. Both S7 and S2 agreed Patient #4 should not had been left alone on 3/9/10 at 10:20 p.m. (2220) and/or 3/11/10 at 12:00 a.m. (0000). S7 reviewed the notes written at 12:25 a.m. (0025), #4's level of consciousness was "Awake" and "Drowsy" at 3:00 a.m. (0300)- about 3 hours after she hit her head when she fell. She indicated there was no documented evidence the physician (S28) was notified of #4's change in condition at 3:00 a.m. by S33RN, Unit 54. She stated the physician (S28) should have been notified of #4's change in condition at 3:00 a.m. by S33RN, Unit 54.

An interview was held with S31LPN, Unit 54, S7, Director, Unit 54 and S5 Quality Director on 4/15/10 from 8:25 a.m. to 9:00 a.m.. S31 LPN reviewed Patient #4's nursing care on 3/9/10 to 3/10/10. He verified he had provided #4 patient care from 7:00 p.m. to 7:00 a.m. (night shift) on 3/9/10 to 3/10/10. He confirmed #4 had a 95 fall risk score, line of site precaution level, chairfast-must be assisted with activity, and required full (maximum/total) assistance with positioning/activities. He indicated full (maximum/total) assistance meant that one hand must be on the patient at all times during activities/positioning. He further indicated that line of site precaution level meant the patient was to visible at all times by a staff member. He agreed the patient was found sitting on the floor on 3/9/10 at 10:20 p.m. (2220)-not visible by nursing staff (S31), nor the tech (S32 MHT) at all times. He agreed the patient should not have been left unattended by the tech (S32 MHT) because #4 was to remain visible to staff at all times and required total assistance with positioning/activities.

An interview was held with S32MHT, Unit 54, S7Director, Unit 54 and S5 Quality Director on 4/15/10 from 9:10 a.m. through 9:45 a.m.. S32MHT reviewed Patient #4's nursing care provided on 3/9/10 to 3/10/10. He verified he was the tech that provided #4 patient care from 7:00 p.m. to 7:00 a.m. (night shift) from 3/9/10 to 3/10/10. He indicated between 9:30 p.m. and 9:45 p.m. (3/9/10) he went and got #4 in her bed-locat