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Based on observation, document review and interview, it was determined that for 3 of 3 patients (Pt. #1, 3, and 4) identified as high fall risks, with Pt #1 sustaining injuries after mulitiple falls, the Hospital failed to ensure fall prevention interventions were implemented or increased. As a result, the Condition of Participation, 42 CFR 482.23, Nursing Services, was not in compliance. Findings include:

1. The Hospital failed to ensure a fall risk assessment was conducted on a patient with prior history fall and fall while in the Emergency Department. (A-0395 A).

2. The Hospital failed to ensure that appropriate fall prevention interventions were implemented for patients. (A-0395 B).

3. The Hospital failed to ensure reassessment for the need of additional intervention after a patient fall with injury (A-0395 C).

The immediate jeopardy began on 6/1/18 when Patient (Pt. #1) presented to the Emergency Department (ED) with a complaint of right knee pain from a fall. The X-ray report dated 6/1/18 indicated a fracture of the patella. On 6/1/18 at 4:20 PM while in the ED, Pt. #1 was found on the floor on the right side. An X-ray on 6/1/18 at 5:56 PM, included, "Intertrochanteric fracture, proximal right femur [thigh bone closest to hip joint]...." Pt. #1 was admitted to the Telemetry Unit on 6/1/18 and later sustained two additonal falls on 6/3/18 and 6/05/18. Two patients in the Intensive Care Unit (Pt. #3 and Pt. #4) had high fall risk scores; however, the bed alarms were turned off. The Hospital failed to increase and implement fall prevention interventions, thus placing all patients on precautions with high risks for falls at risk for serious harm.

The immediate jeopardy was identified and announced on 7/27/18 at 9:25 AM, during a meeting with the Chief Executive Officer, Director of Nursing and Director of System Quality. The immediate jeopardy was not removed by the survey exit date of 7/27/18.

A. Based on document review and interview, it was determined that for 1 (Pt #1) of 2 clinical records reviewed for fall prevention, the Hospital failed to ensure a fall risk assessment was conducted on a patient with prior history fall and a fall while in the Emergency Department(ED). Subsequently, Pt #1 sustained a right hip fracture after a fall in the ED.

Findings include:

1. The Hospital's policy titled, "Falls Prevention Program" (revised 12/12/17) was reviewed on 07/25/18 and required, " ...B. Environment of Care Risk Assessment ...2.Identified risk factors should be addressed immediately ...with the manager/designee ... G. Fall Prevention Consideration in Emergency Departments / Hospitals / Outpatient Departments ...1. Assessment. a. A fall risk assessment tool will be utilized to identify the following patients as "no risk" or "at risk" ...ii. Patients who present with injuries related to falls. Patients with ETOH [alcohol] intoxication, overdose, or ...2. Interventions ... d. if patient is non-cooperative, demonstrates poor comprehension or reduced cognitive responses, use of a sitter should be considered ..."

2. The clinical record of Pt #1 was reviewed on 07/24/18. Pt #1 was a 55 year old female who was brought in by the ambulance to the Emergency Department on 06/01/18 at 1:31 PM, with a chief complaint of right knee pain from a fall while going to the grocery store. The ED triage nurse documented at 1:31 AM, "By ambulance for R [right] knee pain and swelling after fall. Endorses ETOH [alcohol] intake. Denies other pain or injury of any kind ..." The X-ray report on 06/01/18 indicated a fracture of the patella.

At 3:30 PM, E #8's (ED Nurse) notes included, "Knee immobilizer applied ...Patient requested a ride home ...But at 4:20 PM, (Pt #1) "found on floor on right side. (Pt #1) stated that (Pt #1) stood up and fell. (Pt #1) complained of right knee and hip pain ..." An X-Ray on 06/01/18 at 5:56 PM, included, "Intertrochanteric fracture, proximal right femur [thigh closest to hip joint]. Avulsions [pulling away] of the lesser trochanter. Questionable fracture of the right pubic bone." At 7:09 PM, E #8's (ED Nurse) note included, "X-Ray positive for right hip fracture. Noted right hip swelling, ice pack applied. Right leg shorter and externally rotated...."

3. On 07/24/18 at approximately 9:15 AM, an interview was conducted with E #1 (ED Charge Nurse). E #1 stated, "If they are at risk for fall[s] we keep them close to the nurse's station. Any patient that comes to the ED with [a]history of fall[s], we do the "Fall Risk Scoring." E #1 stated, "We discussed this (Pt #1) case during our morning huddle (06/07/18). That day we had a high census. (Pt #1) was placed in the triage room #3. This room has no call light or bed alarm, but the four side rails were up for the triage bed or stretcher. So after the event now, we have a resolution now of having bells in those triage rooms where there is no call light."

4. On 07/24/18 at approximately 9:45 AM, an interview was conducted with E #3 (ED Manager/Intensive Care Unit [ICU] Manager). E #3 stated, "In that particular room there is no call light. Nurses must provide [a] safe environment with fall precautions. (Pt #1) had altered mental status. The bed was low and side rails up. (Pt #1) was educated not to get up without assistance. We now follow the system's policy for falls. We educated our ED nurses to do the fall risk assessment and scoring. The temporary solution we have now is having bells in those rooms without call lights."

5. On 07/24/18 at approximately 3:35 PM, an interview was conducted with E #8 (ED Nurse). E #8 stated, "Yes, I took care of (Pt #1) when (Pt #1) was in the ED triage #3. (Pt #1) was instructed not to get out of bed. (Pt #1) was advised to yell or scream for nurse, as there is no call light in the room. I had the right hand side rails up and door was left open. I did not do fall assessment scoring. (Pt #1) was alert, oriented times three. I did not see her getting out of bed. I do not remember asking for a sitter after the fall. Yes, when [a] patient comes to ED with history of fall[s], we must do a fall risk assessment scoring."

6. On 07/25/18 at approximately 10:48 AM, an interview was conducted with MD #1 (ED Physician). MD #1 stated, "I don't recall seeing the Fall Risk Assessment scoring for (Pt #1), and no, I don't recall ordering a sitter for (Pt #1) after the fall in the ED. (Pt #1) was taken care by an Advance Practitioner before they referred the case to me after the event occurred in the ED.


B. Based on observation, document review and interview it was determined that 2 of 6 (Pt #3 and Pt #4) patients identified as high risk for falls in the Intensive Care Unit (ICU), the Hospital failed to ensure that appropriate fall prevention interventions were implemented for patients.

Findings included:

1. On 07/24/18 at approximately 10:30 AM, during the observational tour of the ICU, Pt. #3 and Pt. #4 were observed with the bed alarms turned off and not activated.

2. The clinical record for Pt. #3 was reviewed on 7/24/18. Pt #3 was a 96 year old male, admitted to the Intensive Care Unit from the Emergency Department [ED] on 07/20/18 with a diagnosis of cellulitis of the great toe and left foot. On 07/20/18 at 4:00 PM, the flow sheet assessment documentation included a fall risk score of 60. On 07/24/18, the flow sheet assessment included the fall risk score of 40. The 07/23/18 plan of care documentation by a nurse included, "Provide a safe, barrier-free environment ...reassess fall/ injury risk to inter professional health care team ...determine need for increased observation, or bed/chair alarms ..."

3. The clinical record for Pt. #4 was reviewed on 7/24/18. Pt #4 was a 71 year old male, admitted to the Intensive Care Unit from the ED on 07/21/18 with diagnoses of fall, head injury, and abnormal lab values. On 07/21/18 at 6:00 PM, the flow sheet assessment included a fall risk score 50. On 07/24/18, the flow sheet assessment included the fall risk score of 65. The fall precautions in the plan of care for Pt#4 included: "barrier free environment, keep area uncluttered, keep needed items within reach, promote use of personal vision/auditory aids, reassess fall risk frequently with change in status and determine need for increased observation, or bed/chair alarms."

4. On 07/24/18 at approximately 10:35 AM, during the observational tour of ICU, it was observed that, Pt #3 and Pt #4's bed alarms were turned off. Upon inquiring with E #6 (ICU Charge RN-Registered Nurse), E #6 stated, "We follow the fall precautions for all the patients in ICU. Bed is kept in low position. Call light is placed within the reach of the patient and bed alarms are turned on, so we can hear as the patient is trying to get out of bed. I am sorry. I am not sure how this bed alarm is turned off."

5. On 07/24/18 at approximately 10:45 AM, an interview was conducted with E #3 (ED Manager/Interim ICU Manager) regarding Pt #3 and Pt #4. E #3 stated, "They should have had the alarms on. It is inexcusable. I cannot speculate what occurred."

C. Based on document review and interview, it was determined that for 1 (Pt #1) of 3 clinical records reviewed for fall prevention, the Hospital failed to ensure reassessment for the need of additional interventions after a patient fall with an injury. Subsequently, Pt. #1 fell a second and a third time, while in the telemetry unit.

Findings include:

1. The Hospital's policy titled, "Falls Prevention Program" (revised 12/12/17) was reviewed on 07/25/18 and required, " ...B. Environment of Care Risk Assessment ...2.Identified risk factors should be addressed immediately ...with the manager/designee ... G. Fall Prevention Consideration in Emergency Departments/Hospitals/Outpatient Departments ...1. Assessment... a. A fall risk assessment tool will be utilized to identify the following patients as "no risk" or "at risk" ... 9. All patients identified at risk for fall should have all standard interventions and the following "at risk" interventions implemented...Consider the use of sitter/remote sitter."

2. The clinical record of Pt #1 was reviewed on 07/24/18. Pt #1 was a 55 year old female who was brought in by the ambulance to the Emergency Department on 06/01/18 at 1:31 PM, with a chief complaint of right knee pain from a fall. The 06/01/18 X-ray report indicated a fracture of the patella [knee]. At 3:30 PM, E #8's (Emergency Department-ED Nurse) note included, "Knee immobilizer applied ...Patient requested a ride home ...But at 4:20 PM, (Pt #1) "found on floor on right side. (Pt #1) stated that (Pt #1) stood up and fell. (Pt #1) complained of right knee and hip pain ..." An X-Ray on 06/01/18 at 5:56 PM, included, "Intertrochanteric fracture, proximal right femur [thigh bone closest to hip joint]...." Avulsions [pulling away] of the lesser trochanter. Questionable fracture of the right pubic bone." At 7:09 PM, E #8's (ED Nurse) notes included, "X-Ray positive for right hip fracture." Pt #1 was admitted to the Telemetry Unit at 8:37 PM.

The progress note documentation on 06/03/18 at 5:43 AM, by E #11 (Telemetry Nurse) included, "(Pt #1) is alert and oriented times four. Cooperative and calm with care at the beginning of the shifts ...While transfusing one unit of PRBC (Packed Red Blood Cells), patient tried to get out of bed and fell, unwitnessed ...she wanted to walk ...MD notified and CT (Computerized Tomography) of the head ordered ...no acute findings seen on results ...Fall precautions maintained ...bed alarm activated and audible, call light in reach."

The plan of care documentation on 06/05/18 at 3:23 AM, by the Resident Physician included, "RN [Registered Nurse] paged regarding unwitnessed fall. Patient seen and examined. She [Pt #1] says she [Pt. #1] tumbled over the bed railing in her sleep and fell on the floor but denies head trauma ... no obvious sign of injury ..."

3. On 7/25/18 at approximately 2:52 PM, an interview was conducted with MD #2 (Attending Physician). MD #2 stated, "This is a sad story. There should have been a sitter for this patient after the second fall. The question then goes to nursing services. If the bed alarm goes off, and fall precautions are in place, then we could have avoided these other falls."