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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 Quality Assessment and Performance Improvement Program was out of compliance.

A-0283 Quality Improvement Activities §§482.21(b)(2)(ii), 482.21(c)(1) & 482.21 (c)(3) §482.21(b)(2) Standard: Program Data, The hospital must use the data collected to-- ... (ii) Identify opportunities for improvement and changes that will lead to improvement. §482.21(c) Standard: Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. Based on observations, interviews, and document review, the facility failed to ensure the quality assessment and performance improvement (QAPI) program identified and implemented performance improvement activities, including in high-risk, problem-prone areas.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services was out of compliance.

A-0392 Staffing and Delivery of Care The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on observations, interviews, and document reviews, the facility failed to ensure nursing staff was available to provide nursing care to all patients as needed. Specifically, the facility failed to ensure nursing staff routinely monitored patients in 13 of 15 medical records reviewed (Patients #3 through #15). The facility also failed to ensure nursing staff comprehensively assessed patients after a fall according to facility policy (Patients #1 and #3).

Based on observations, interviews, and document review, the facility failed to ensure the quality assessment and performance improvement (QAPI) program identified and implemented performance improvement activities, including in high-risk, problem-prone areas. (Cross-reference A-0392)

Findings include:

Facility policies:

According to the Performance Improvement and Safety Plan policy, the purpose is to improve safety and quality for patients. The program identifies and manages risks to safety and elevates expectations and outcomes. The ultimate responsibility for the implementation and operation of this Plan is the hospital CEO. The Quality Council is responsible for overseeing the Plan by monitoring and assessing data, identifying and prioritizing performance improvement projects that address recognizable gaps, and analyzing gaps and opportunities for leadership and governance development to improve safety standards. Organizational performance activities and projects are judged and prioritized based on their impact.

The performance improvement activities of the hospital are a comprehensive and ongoing effort to assess the effectiveness of all care and services provided. These activities require a proactive approach on all levels of the organization. The facility strives for optimal outcomes with continuous improvements which consistently represent a high standard of practice.

The plan is to minimize risks to patients while improving the quality and safety of patient care. The organization shall utilize a systematic method to improve the organizational performance. The most effective and simplest method is the use of the Plan, Do, Check, Act (PDCA) model.

Data is the foundation of performance improvement activities. Analysis of data and implementation of actions following data analysis can enable widespread learning necessary for improving best practice guidelines and promoting safety. Actions based on the data and information obtained improve the performance of the organization. Opportunities for performance improvement may be identified by the systematic review of the obtained data.

According to the Sentinel Event policy, all unanticipated adverse outcomes require investigation and evaluation. Certain events, such as sentinel events, signal the need for prompt, in-depth investigations. This policy will also establish acceptable analysis tools for the review of these events. The goals are to positively impact care, treatment, and services by identifying opportunities to change culture, systems, and processes to prevent unintended harm, to determine and understand contributing factors (including underlying causes, latent conditions, and active failures), and develop strategies to prevent or reduce such events in the future.

This policy ensures proper management, trending, and analysis of actual or potential sentinel events via the performance of a root cause analysis (RCA). RCA is the process of identifying the basic or contributing causal factors that underlie variations in performance. A sentinel event is a patient safety event that reaches a patient and signals a need for immediate investigation and response. Sentinel events are events that result in death, permanent harm (an event or condition that reaches the patient, resulting in any level of harm that permanently alters and/or affects an individual ' s baseline health), or severe harm (an event or condition that reaches the individual, resulting in life-threatening bodily injury including pain or disfigurement that interferes with or results in loss of functional ability or quality of life that requires continuous physiological monitoring and/or surgery, invasive procedure, or treatment to resolve the condition). Sentinel events are also falls which result in a fracture, surgery, or casting, or permanent harm as a result of injuries sustained from the fall.

Falls are sentinel events requiring a reviewable RCA (goes to the regional and corporate offices). The CEO and/or the director of quality and risk will be responsible for initiating a timely and thorough RCA. The first draft of the reviewable RCA goes to the regional quality director within 30 days of the event or notice of the event and to the facility's corporate office within 45 days. Once the final version has been reviewed and approved, the facility will attach the completed RCA to the appropriate event report.

1. The facility failed to ensure the QAPI program identified and implemented performance improvement activities, including in high-risk, problem-prone areas such as fall prevention.

A. Observations of video footage

i. A review of video footage dated 5/30/24 from the patient care area revealed the presence of several staff members in the hallway outside of Patient #3's room when, according to the director of quality and risk (Director) #8, Patient #3's bed alarm alerted. The footage revealed a rehabilitation nursing technician (RNT) running down the hallway towards the room identified by Director #8 as Patient #3's room, while a registered nurse (RN), identified as RN #1, Patient #3's assigned nurse, sat at a computer. Another RN entered from the opposite direction and entered Patient #3's room after the RNT.

B. Document review and interviews revealed QAPI staff had not identified the nursing staff's failure to round on and monitor patients as contributing factors to Patient #3's fall and subsequent fracture.

i. A review of medical records for Patients #3, #4, #7, #11, and #13 revealed nursing staff failed to round on patients for periods ranging from three to seven hours during the night on 5/29/24 and early morning hours on 5/30/24. Record review revealed patient rounding was when staff typically provided toileting assistance and other care as well as safety checks of the patients and their environment.

A review of Patient #3's medical record revealed they had a post-residual void (PRV) over 700 milliliters (mL) on 5/29/24 at 11:00 p.m. which according to their provider's orders, required catheterization although the catheterization was not performed. As a result of the nursing staff's failure to round, along with their failure to follow provider orders for elimination, and with a patient history of urinary retention, Patient #3 exited the bed, fell, hit their head, and fractured their hip which required transfer to the emergency department (ED).

ii. A review of the incidents revealed an event report (incidents) created after Patient #3's fall on 5/30/24. The event report, dated 5/30/24, and follow-up, dated "current summary 7/10/24," revealed RN #1's report of Patient #3's fall. The follow-up revealed the facility's immediate actions consisted of the application of a dressing to a skin tear (wound in the skin), an assessment of the patient, a fall huddle (post-event meeting), a neurological assessment, a medication review, and patient transfer to a higher level of care. The resolution section read this event was classified as a "major injury" and the expected completion date of the root cause analysis (RCA) was 6/29/24. There was no evidence in the event report that identified the gap of patient rounding as a potential contributing factor in the fall.

iii. During an interview with Director #8 on 7/15/24 at 11:45 a.m., they stated the RCA was still in progress. They stated the initial action plan to address potential gaps in care, 46 days after the event with Patient #3, focused on re-educating staff on toileting and post-void residuals (PVR) (urine remaining in the bladder after urination) although these action items were also in progress.

This delay in enacting changes after an event (incident) was in contrast to the Performance Improvement and Safety Plan policy which read, the QAPI plan minimized risks to patients while improving the quality and safety of patient care.

C. A review of the medical records and incident reports revealed QAPI staff had not identified an RN staff's failure to thoroughly assess patients after falls, including one such fall that resulted in a fracture and transfer to the ED.

i. A review of medical records for Patients #1 and #3 revealed nursing staff failed to conduct a thorough and comprehensive assessment after these patients fell out of bed. Patient #3 fell out of bed, striking their head and side, on 5/30/24. According to the provider note on 5/30/24, RN #1 was prompted by the patient's physician to conduct a thorough physical assessment of the patient after initially assessing only their skin for injury. Patient #1 fell out of bed, landing on their side, on 6/3/24, four days after Patient #3's fall. Although Patient #3's similar fall had resulted in a hip fracture and transfer to the ED, Patient #1's RN failed to assess Patient #1's skin or joints in the post-fall assessment.

ii. A review of the incidents revealed an event report created after Patient #3's fall on 5/30/24. The event report, dated 5/30/24, and follow-up, dated "current summary 7/10/24," revealed RN #1's report of Patient #3's fall. The follow-up revealed the facility's immediate actions consisted of the application of a dressing to a skin tear (wound in the skin), an assessment of the patient, a fall huddle (post-event meeting), a neurological assessment, a medication review, and patient transfer to a higher level of care. This event was still undergoing RCA, however, the facility's follow-up had not identified gaps in RN #1's nursing assessment post-fall or identified post-fall assessments as opportunities for improvement.

iii. A review of the incidents revealed an event reported created after Patient #1's fall on 6/3/24. The event report, dated 6/3/24, and the closed follow-up dated "current summary 7/10/24" revealed an RN report of Patient #1's fall. The follow-up revealed immediate actions consisted of diagnostic testing, patient assessment, and a fall huddle. The resolution section read this incident was scored as an "injury (except major) with pain as the outcome. No other follow-up actions or opportunities for improvement were documented as a result of Patient #1's fall.

QAPI's failure to identify gaps in the nurses' post-fall assessments after incident reports were created and follow-up actions were taken was in contrast to the Performance Improvement and Safety Plan policy which read, the QAPI plan minimized risks to patients while improving the quality and safety of patient care.

D. Interviews

i. On 7/11/24 at 11:24 a.m., 7/11/24 at 3:38 p.m., and 7/15/24 at 8:59 a.m., interviews were conducted with the director of quality and risk (Director) #8. Director #8 stated they were primarily responsible for quality within the facility although other facility leadership collaborated on quality improvement activities. They stated they did not have a medical or clinical background as they previously worked in case management and public health. Director #8 stated they felt comfortable in their ability to fulfill this role without additional facility support as they received support from quality directors at other facilities within their network as well as their regional quality director.

Director #8 stated they and department leaders reviewed incidents and worked through the follow-ups. They stated they reviewed the medical records, discussed the patient falls with the physicians, and followed the Centers for Medicare and Medicaid Services (CMS) guidelines to create a patient harm score from falls. Director #8 stated they did not rely solely on the post-fall nursing assessment to determine harm scoring. Director #8 stated they had not identified a gap in post-fall patient assessment after Patient #1 and #3's falls although they had previously stated Director #8 conducted a thorough medical record review during the fall investigations.

Director #8 stated Patient #3's fall with injury had been identified as a sentinel event (an incident causing patient death, permanent harm, or severe harm) which necessitated a root cause analysis (RCA). They stated the RCA into Patient #3's fall had not yet been completed, however they had identified toileting as a major contributing factor to the fall. Director #8 stated their analysis revealed Patient #3 had met the parameters for urinary catheterization on 5/29/24, however, this action had not been taken. They stated Patient #3 felt urinary urgency on 5/30/24 and left the bed quickly, at which point they fell to the floor. They stated the quality team had developed action items based on the RCA which were aimed at improving adherence to toileting schedules and retraining staff on post-void residuals (PVR). In the 7/11/24 interview, Director #8 stated once these action items were approved, the goal was to roll them out starting 7/15/24.

In the 7/15/24 interview, Director #8 stated the timeline for this RCA, which was still under investigation 46 days after Patient #3's fall, and the actions taken as a result were on par with previous RCAs and action plans. They stated the action plan items regarding adherence to urinary elimination and post-void residuals, although this was not yet approved and was potentially still open to change, were actions the facility was taking to ensure patient safety until the RCA was completed. They stated the quality team had not taken any other actions to ensure the safety of patients. This was in contrast to the event follow-up which read the RCA was expected to be completed as of 6/29/24.

Director #8 stated staff were instructed in staff meetings on 5/28/24-5/30/24 to round "purposefully" instead of hourly, to move towards patient-specific rounding expectations. A lack of hourly and purposeful rounding was observed in a review of Patient #3's medical record which failed to reveal rounding, monitoring, and care on a patient with previously identified elimination needs.

Director #8 stated the quality team identified performance improvement (PI) opportunities through investigations of incidents, patient rounding, proactive risk assessments, staff suggestions, committees, and conversations with staff. This was in contrast to a review of quality documents which did not reveal identification of patient rounding and monitoring or lack of thorough post-fall patient assessment as PI opportunities. They stated they identified low-volume, high-risk problems through education, staying up to date with guidelines and standards, analysis of patient medical records, and auditing invasive procedures like blood transfusions. Director #8 stated QAPI was important to ensure patient rights were protected. They stated if there was a gap in QAPI, patients were at risk of harm, a delay in care, and potentially recovery long-term.

This interview was in contrast to the Performance Improvement and Safety Plan policy which read, QAPI minimized patient risk while improving the quality and safety of patient care. QAPI identified and prioritized performance improvement projects which addressed gaps in patient safety.

ii. On 7/11/24 at 11:43 a.m., an interview was conducted with nurse manager and interim chief nursing officer (CNO) #10. They stated they were part of the quality team in their capacity as the interim CNO.

CNO #10 stated staff had filed an incident report when Patient #3 fell which they had reviewed in their role as the nurse manager and CNO. CNO #10 stated the quality team was still working on the RCA, 42 days after the incident had occurred. They stated the quality team had identified Patient #3 was not catheterized per the provider's orders. CNO #10 stated the current focus of the in-progress RCA was on re-educating nursing staff on bladder management.

CNO #10 stated after Patient #3's fall, their immediate response was to ask RN #1, the patient's nurse, to respond more quickly to bed alarms. They stated they had instructed RNT #2, the patient's RNT, who was in the bathroom at the time of Patient #3's fall, to obtain floor coverage for patient care while on break. CNO #10 stated they and the quality team had not previously identified a gap in patient rounding on 5/29/24 or 5/30/24 for Patient #3 or any of the other patients' RN #1 and RNT #2 were assigned to care for including Patients #4, #7, #11, and #13. This was in contrast to the Performance Improvement and Safety Plan policy which read, QAPI minimized patient risk while improving the quality and safety of patient care. QAPI identified and prioritized performance improvement projects which addressed gaps in patient safety. CNO #10 stated they were concerned with this gap in patient rounding.

iii. On 7/11/24 at 2:47 p.m., an interview was conducted with Physician #4. Physician #4 stated they were one of the medical directors at the facility and a part of the quality team. They stated they participated in case reviews for the RCAs. Physician #4 stated QAPI impacted patient care by improving patient outcomes. They stated if quality was not actively identifying performance improvement opportunities to ensure better patient care, there was an increased risk for falls, delays in care, wounds, low blood sugar, medication errors, and adverse events.

Physician #4 stated actions had been taken to ensure Patient #3's safety when Patient #3 was at the facility, although Patient #3 had later fallen and fractured their hip. They stated these actions included eliminating the patient's catheter to reduce the risk of infection, monitoring urination, moving the patient closer to the nursing station, using a bed with a bed alarm, and instituting timed voiding. This lack of recognition of gaps in care was in contrast to a review of the medical records which revealed Patient #3 was unmonitored, provider orders were not followed, and Patient #3 suffered a negative outcome.

This physician interview was in contrast to the Performance Improvement and Safety Plan policy which read, QAPI minimized patient risk while improving the quality and safety of patient care. QAPI identified and prioritized performance improvement projects which addressed gaps in patient safety.

iv. On 7/11/24 at 2:14 p.m., an interview was conducted with chief executive officer (CEO) #11. CEO #11 stated they provided oversight to Director #8 and the QAPI program overall. They stated incidents were reviewed by Director #8, CNO #10, and the regional director of quality before the follow-ups were assigned to various departments. CEO #11 stated they reviewed the quality and timeliness of Director #8's work as part of their oversight.

CEO #11 stated performance improvement was driven by patient safety. They stated performance improvement opportunities were identified through communication with staff at all levels across the facility, collecting and analyzing data, tracking and trending, and involving multiple departments in the quality efforts. CEO #11 stated the facility created scorecards with metrics and took action in the areas with sustained fallouts. They stated incidents with outcomes were also opportunities for performance improvement opportunities.

CEO #11 stated they had discussed the importance of rounding in the nursing supervisors' meeting the previous day. They stated quality rounding and timing of rounding was an area CNO #10 focused on during their quality improvement and patient safety discussions with nursing staff. CEO #11 stated patient rounding and provision of patient care were important as there was no excuse for a patient to wait for care. This was in contrast to a review of the medical records for Patients #3, #4, #7, #11, and #13 which failed to reveal QAPI's recognition of gaps in patient rounding and monitoring.

CEO #11 stated they had brought in the regional quality director to assist Director #8 with the creation of Patient #3's RCA and the development of subsequent action plans. They stated the quality team had not recognized a lack of monitoring as a contributing factor in Patient #3's fall, subsequent injury, and transfer to an acute hospital. CEO #11 also stated QAPI had not recognized a lack of thorough post-fall patient assessment for Patients #1 and #3. This was in contrast to the Performance Improvement and Safety Plan policy which read, QAPI minimized patient risk while improving the quality and safety of patient care. QAPI identified and prioritized performance improvement projects which addressed gaps in patient safety.

CEO #11 stated the quality department was responsible for upholding standards and improving performance. CEO #11 stated QAPI efforts were paramount for ensuring patient safety.

Based on observations, interviews, and document reviews, the facility failed to ensure nursing staff was available to provide nursing care to all patients as needed. Specifically, the facility failed to ensure nursing staff routinely monitored patients in 13 of 15 medical records reviewed (Patients #3 through #15). The facility also failed to ensure nursing staff comprehensively assessed patients after a fall according to facility policy (Patients #1 and #3).

Findings include:

Facility policies:

According to the Assessment, Reassessment policy, all inpatients will be assessed and reassessed. Assessment and reassessment occur per regulatory and state-specific requirements and more frequently as indicated by patient condition. Reassessments are performed according to the patients' vital signs, status, or condition. Registered nurses (RN) conduct daily reassessments of the patient's condition. Reassessment is ongoing and occurs at designated intervals to determine the response to and effectiveness of certain care, treatment, and services received. Reassessment provides ongoing data about the patient's biophysical, psychological, and social needs. The scope and intensity of the reassessment are based on the patient's diagnosis, care setting, and patient's response to previous care.

According to the Fall Risk Prevention policy, the program is designed to reduce the risk of falls with an emphasis on patient-related falls. If a patient is designated "high risk" the patient will have the following: bed alarm, specialty low bed, supervision at all times, 1:1 handoff, and toileting schedule. Post-fall procedures include the initial post-fall assessment, documentation, and follow-up. The priority is to assess the patient for any obvious injuries and discover what happened. A post-fall assessment will be performed by a clinician and any obvious injuries or change in status must be thoroughly evaluated. The staff will assess vital signs, notify the physician, and conduct a review of current medications. The interdisciplinary team will determine the need for revision of a patient's fall prevention interventions.

According to the Alarm Management policy, the purpose is to promote the monitoring of patients through the use of, and response to, clinical alarms. Clinical alarms include patient care equipment alarms such as bed and chair alarms (a warning to staff when patients exit their beds or chairs). Clinical caregivers will monitor and respond to alarm signals.

1. The facility failed to ensure nursing staff routinely monitored patients to ensure patients health and safety which contributed to a patient fall and fracture (broken bone).

A. Observations

i. On 7/11/24 at 11:24 a.m., observations were conducted with the director of quality and risk (Director) #8 of video footage obtained on 5/30/24 from the hallway outside Patient #3's room. The video footage was time-stamped "5/30/24" and the time started at 4:43 a.m. The footage revealed a patient care area with an RN sitting mid-way down the hallway at a computer station and a nursing station at the end of the hall. At 4:44 a.m. (according to the timestamp), a staff member walked down the hallway toward the nursing station. As they reached the halfway point, the staff member started to run towards a patient's room at the end of the hall. According to Director #8, this staff member was a rehabilitation nursing technician (RNT) who just heard and saw Patient #3's bed alarm sound, although the video footage had not captured the sound or appearance of the alarm. Director #8 stated the room the RNT had entered was Patient #3's room.

The footage revealed another staff member, an RN according to Director #8, entering Patient #3's room from the direction of the nursing station. During this time, the RN in the hallway failed to respond to Patient #3's bed alarm. According to Director #8, this was RN #1, Patient #3's assigned nurse. They stated the video footage also failed to reveal RNT #2, who was assigned to care for Patient #3, responding to the bed alarm.

During this observation, Director #8 acknowledged the time stamp of the incident (4:44 a.m.) did not match the time of the incident documented in the medical record (approximately 5:00 a.m.). They stated the facility had since recalibrated the cameras as the recorded timestamp was 17 minutes off the actual time.

This observation of video footage revealed RN #1 and RNT #2 failed to monitor and respond to their patient's (Patient #3) bed alarm which was in contrast to the Alarm Management policy which read, clinical caregivers monitored and responded to alarm signals.

B. Document review

i. Upon request, the facility was unable to provide a policy on the expectations for patient rounding.

ii. A review of medical records revealed patients were unmonitored overnight for periods ranging from three to seven hours. During a lapse in monitoring, Patient #3, a 74-year-old with a history of a brain injury, to fall from bed resulting in a fractured (broken) hip and transfer to an emergency department (ED).

a. A review of medical records revealed Patient #3 was admitted on 5/17/24 for acute rehabilitation services due to a subdural hematoma (a collection of blood between the brain and the outermost covering which puts pressure on the brain tissue), seizures (abnormal electrical activity in the brain), and dementia (declining cognitive function). Provider progress notes revealed the providers considered Patient #3 a high fall risk and had ordered high fall risk precautions. These high fall-risk precautions included a bed alarm, three bed rails up, toileting assistance offered every three hours when awake, and a chair alarm. On 5/22/24, the Interdisciplinary Plan of Care nursing outcomes and summary section read, the patient needed 1:1 supervision at all times for their safety. This was in contrast to a lack of provider orders for 24/7 supervision or 1:1 monitoring during Patient #3's stay. On 5/29/24 at 8:19 a.m., a provider progress note read the patient was moved closer to the nursing station due to agitation and impulsivity. In this note, the provider documented Patient #3 had worsening urinary retention (excessive urine in the bladder) and needed toileting on schedule. On 5/29/24 at 2:32 p.m., a provider order read staff were to assess Patient #3's post-void residual (PVR) (amount of urine remaining in the bladder post-urination) every six hours. If the volume of urine in the bladder exceeded 500 milliliters (mL), the staff was to insert a catheter (tubing inside the bladder to assist with urinary elimination).

On 5/30/24 at 5:00 a.m., nursing notes revealed Patient #3 fell out of bed. The Post Fall Assessment by RN #1 revealed RN #1 observed a skin tear (a traumatic wound of the skin) and then later noted a "bump" on the head. RN #1 also wrote the patient complained of hip and knee pain. The Discharge Summary by Physician #4 on 5/30/24 read staff informed Physician #4 of Patient #3's fall and resultant skin tear. The note read Physician #4 asked the nurse to perform a more thorough evaluation of Patient #3, which revealed Patient #3's head strike. At this time, Physician #4 ordered Patient #3 to be transferred to the ED at a nearby hospital and requested staff insert a Foley catheter (tubing inside the bladder to assist with urinary elimination) as the patient had over 700 mL (normal 50-100 mL) of urine in their bladder, as documented earlier in the medical record. An imaging report from an X-ray of the hip was attached to the Discharge Summary, although no provider orders for the X-ray were found in the medical record. The X-ray report revealed Patient #3 had fractured their left femur (thigh bone) where it connected to the hip.

On 5/29/24 at 11:00 p.m., the patient rounding (purposeful monitoring of patients) notes revealed RNT #2 had rounded on Patient #3 and assisted them with toileting. At this time, RNT #2 assessed the PVR at 717 mL. In contrast to the provider order from earlier that day which instructed staff to insert a urinary catheter if the volume exceeded 500 mL, the patient was not catheterized but was provided a disposable brief. On 5/30/24 at 1:00 a.m. (two hours later), RNT #2 offered Patient #3 elimination assistance which they declined. The record failed to reveal evidence of additional rounding until 5:00 a.m. (four hours later), at which point Patient #3 had fallen out of bed.

This failure to perform patient monitoring was in contrast to an interview with RN #7 on 7/10/24 at 9:55 a.m. during which they stated the patient monitoring performed during hourly rounds allowed staff to intervene more quickly to changes in condition and a patient's response to treatment. This was also in contrast to an interview with RNT #5 on 7/11/24 at 10:30 a.m. during which RNT #5 stated patient rounding was performed to meet patients' needs, including toileting and if those needs were not met, patients could fall or injure themselves seeking assistance.

This review of Patient #3's medical record which revealed a gap in patient monitoring was further in contrast to the Assessment and Reassessment policy which read, reassessments were performed according to a patient's status or condition. Reassessment provided ongoing data about the patient's needs.

b. A review of medical records revealed Patient #13 was an 86-year-old patient. Patient #13 was admitted on 5/18/24 for acute rehabilitation services due to sepsis (an infection in the blood causing inflammation, organ failure, and death).

On 5/29/24 and 5/30/24, the patient rounding notes revealed nursing staff failed to round on the patient from 5/29/24 at 11:18 p.m. to 5/30/24 at 6:42 a.m. This gap in patient monitoring lasted seven hours and 24 minutes.

c. A review of medical records revealed Patient #4 was a 31-year-old patient. Patient #4 was admitted on 5/17/24 for acute rehabilitation services due to Ehlers-Danos syndrome (EDS) (a connective tissue disorder affecting the joints and skin).

On 5/30/24, the patient rounding notes revealed nursing staff failed to round on Patient #4 between 1:37 a.m. to 6:06 a.m. (a gap of 4 hours and 29 minutes).

d. A review of medical records revealed Patient #7 was a 75-year-old patient. Patient #7 was admitted on 5/21/24 for acute rehabilitation services due to "major multiple trauma."

On 5/29/24 and 5/30/24, the patient rounding notes revealed nursing staff failed to round on the patient from 5/29/24 at 10:01 p.m. to 5/30/24 at 1:48 a.m. (a gap of three hours and 47 minutes) and on 5/30/24 between 1:48 a.m. and 6:40 a.m. (a gap of four hours and 52 minutes).

e. A review of medical records revealed Patient #11 was a 44-year-old patient. Patient #11 was admitted on 5/23/24 for acute rehabilitation services due to a stroke (lack of blood flow to the brain causing tissue death).

On 5/29/24 and 5/30/24, the patient rounding notes revealed nursing staff failed to round on the patient from 5/29/24 at 9:47 p.m. to 5/30/24 at 2:17 a.m. (a gap of four hours and 30 minutes) and between 5/30/24 at 2:18 a.m. to 6:15 a.m. (a gap of three hours and 57 minutes).

f. Similar findings of gaps in monitoring were found in the medical records for Patients #5, #6, #8, #9, #10, #12, #14, and #15.

This review of the medical records for Patients #1 and #3 - #15 which revealed gaps in patient monitoring was in contrast to an interview with Director #8 on 7/11/24 at 9:02 a.m., during which they stated RNs and RNTs were expected to perform hourly rounds. This review was also in contrast to interviews with RN #7 on 7/10/24 at 9:55 a.m. and RNT #5 on 7/11/24 at 10:30 a.m. during which they stated hourly rounding allowed staff the opportunity to meet patients needs more quickly as patients could fall or injure themselves seeking help. Additionally, they stated nursing staff were aware of, and intervened more quickly to, changes in condition with consistent and frequent monitoring.

C. Interviews

i. On 7/11/24 at 10:30 a.m. an interview was conducted with RNT #5. RNT #5 stated they rounded on patients constantly to anticipate patient needs. They stated if patient needs were met, there was a decreased risk of patients exiting their beds and potentially falling while waiting for staff assistance. RNT #5 stated the facility expected staff to respond to bed alarms as soon as possible, as patients exiting their beds could fall or hang themselves.

ii. On 7/10/24 at 10:25 a.m., an interview was conducted with RNT #9. RNT #9 stated they were a preceptor at the facility. They stated RNTs were responsible for answering call lights, bathing, and offering toileting assistance. RNT #9 stated the RNs and RNTs rotated regular monitoring of patients. They stated a prompt response to patient needs ensured patients were provided care which preserved their dignity, health, and safety. This was in contrast to a review of the medical records for Patients #3, #4, #7, #11, and #13 which did not reveal regular monitoring by staff on 5/29/24 and 5/30/24 to ensure patients' needs were met.

iii. On 7/11/24 at 10:46 a.m., an interview was conducted with RN #6. RN #6 stated they treated all patients as high fall risks to ensure every patients' safety. They stated the RNs and RNTs rounded on patients every hour, day or night, and documented their monitoring in the medical record. This was in contrast to a review of the medical records for Patients #3, #4, #7, #11, and #13 which did not reveal hourly rounding on 5/29/24 and 5/30/24. RN #6 stated nighttime rounding was especially important as patients were more disoriented at night and attempted to care for their own needs without waiting for staff.

iv. On 7/11/24 at 2:47 p.m., an interview was conducted with physician and medical director (Physician) #4. Physician #4 stated rounding was important to alert staff to changes in patient condition. They stated they expected RNs and RNTs to round hourly for patient monitoring and assistance with toileting needs, which was in contrast to a review of the medical records for Patients #3, #4, #7, #11, and #13. Physician #4 stated patients who needed to urinate were more likely to get out of bed on their own which was why providers included an order for scheduled toileting with staff assistance in the high fall risk precautions. This was in contrast to a review of Patient #3's medical record which failed to reveal staff adherence to provider orders for urinary elimination. Physician #4 also stated they believed nighttime staff used the call light and bed alarms to alert them to patient care needs rather than rounding on patients hourly.

Physician #4 stated patients who fell while at the facility for rehabilitation services were at risk of of subdural hematoma (bleeding in the brain) which could be life-threatening, fractures, untreated pain, and vascular (artery or vein) injury which could decrease blood flow to a limb. They stated many patients at the facility were also on blood thinners which created an additional risk for injury.

Physician #4 stated Patient #3's fall put them at an increased risk for a prolonged stay at the hospital, debility (weakness), and possible loss of life. They stated the surgery to repair a hip fracture created a risk for infection and decreased cognitive function from the anesthesia. Physician #4 stated overall, Patient #3 came to the facility for rehabilitation services after a fall with injury, and this recent fall which caused a hip fracture set the patient back in their recovery process.

v. On 7/11/2024 at 9:02 a.m., an interview was conducted with the director of quality and risk (Director) #8. Director #8 stated they did not have a nursing or medical background. They stated Patient #3 was moved closer to the nurses' station on 5/29/24 due to impulsivity and agitation which was a concern for the patient's safety. Director #8 stated moving rooms provided Patient #3 with faster response times and closer monitoring from staff which was in contrast to a review of Patient #3's medical record which failed to reveal regular monitoring on 5/29/24 and 5/30/24. Director #8 stated their expectation was for the RNs and RNTs to have rounded every hour and there was a gap in rounding on Patient #3 from 5/30/24 at 1:00 a.m. until 5:00 a.m. when the patient fell out of bed.

Director #8 stated although the notes from Patient #3's interdisciplinary plan of care on 5/22/24 read the patient needed 1:1 supervision at all times for their safety, the providers never ordered 24/7 supervision or a sitter, and the patient was never provided with constant monitoring. Director #8 stated if the nurses had felt a sitter was needed, they could have provided Patient #3 with closer monitoring even without a provider order.

2. The facility failed to ensure nursing staff comprehensively assessed patients after a fall according to facility policy.

A. Document review

i. A review of medical records revealed Patient #3 had a history of a subdural hematoma, seizures, and dementia. However, on 5/30/24 at 5:00 a.m., when Patient #3 fell out of bed, the Post Fall Assessment by RN #1 and the Discharge Summary by Physician #4 revealed RN #1 initially assessed only the patient's skin and had to be prompted to complete a more thorough patient assessment, including an assessment of the head and joints. The nursing notes revealed Patient #3 complained of left hip and knee pain at this time which aligned with the X-ray report reading Patient #3 had fractured their left femur.

This lack of initial assessment after a fall resulting in injury was in contrast to an interview conducted with RN #7 on 7/10/24 at 9:55 a.m., during which they stated patient reassessment was important for nursing staff to ensure changes in condition were caught and communicated to the treating provider.

This lack of thorough assessment after Patient #3 fell was also in contrast to the Assessment and Reassessment and Fall Risk Prevention Policies which read, after a patient fall, the patient was thoroughly assessed for injuries and change in status. During a patient's stay at the facility, reassessments provided ongoing data about a patient's needs and were performed according to the patient's condition.

ii. A review of medical records revealed Patient #1 was admitted to the facility on 5/28/24 for acute rehabilitation services after an intraparenchymal hemorrhage (IPH) (bleeding within the brain). On 6/3/24 at 5:15 a.m., Patient #1 fell out of bed landing on their right side and hip. The Post Fall Assessment revealed the RN had assessed the patient's consciousness, orientation and affect, facial symmetry and speech, vitals including oxygen saturation, blood pressure, heart rate, location and severity of pain, and body temperature. The medical record failed to reveal a comprehensive assessment of Patient #1, including skin or joints, until the provider's assessment and imaging on 6/3/24 at 7:35 a.m., 2 hours and 20 minutes later, revealed the patient had not fractured their spine or pelvis.

Patient #1's fall from bed occurred only four days after Patient #3 had fallen from bed and fractured their femur while at the facility, which resulted in a transfer to the ED. The lack of a thorough nursing assessment of Patient #1 was in contrast to an interview conducted with RN #7 on 7/10/24 at 9:55 a.m., during which they stated it was important for nursing staff to assess patients to ensure changes in condition were caught and communicated to the treating provider.

This lack of thorough assessment after Patient #1 fell was also in contrast to the Assessment and Reassessment and Fall Risk Prevention policies which read, after a patient fall, the patient was thoroughly assessed for injuries and change in status. During a patient's stay at the facility, reassessments provided ongoing data about a patient's needs and were performed according to the patient's condition.

B. Interviews

i. On 7/11/24 at 10:46 a.m., an interview was conducted with RN #6. RN #6 stated they treated all patients as high fall risks to ensure every patient's safety. RN #6 stated falls led to skin tears, bruises, pain, and occasionally major injuries such as fractures. They stated the post-fall assessment included an assessment of potential head injuries, skin shearing or other skin concerns, and changes in joint mobility or increased pain which was in contrast to a review of Patient #1 and #3's medical records which revealed no evidence of including all of these . RN #6 stated the post-fall assessment was important to ensure changes in patient condition were treated immediately.

ii. On 7/11/24 at 9:58 a.m., an interview was conducted with CNO #10. CNO #10 stated staff assessed patients head to toe after a fall with a specific focus on the areas which were more likely to have been injured, such as a head strike and skin abrasions or tears. They stated nurses palpated all areas, head to toe, and assessed joint range of motion (ROM) to ensure the patient was not injured. CNO #10 stated staff considered whether the patient was a reliable historian due to confusion or disorientation as the patients were often unaware of how they fell or what was injured. They stated nursing staff documented their assessment of all body systems, including a head strike, in the post-fall assessments.

CNO #10 stated it was important to thoroughly assess patients for injury after a fall. They stated the harm of not conducting a thorough assessment could include major injuries such as broken bones, head strikes with a brain injury, and skin or wound injuries, as well as the negative repercussions of a fall on a patient's mental well-being, which caused feelings of upset or defeat.

iii. On 7/11/24 at 2:47 p.m., an interview was conducted with Physician #4. Physician #4 stated nurses assessed patients' cognition and injury post-fall. They stated if the patient had previously had a stroke or other brain injury which impaired cognition, physical assessment of the patient by palpation was necessary. Physician #4 stated the post-fall nursing assessment was important as the providers relied on the nursing assessment to triage (determine urgency of the situation) the patient. They stated providers always evaluated a patient after a fall, although the providers relied on nursing to determine the extent of the examination. Physician #4 stated the provider note was as simple as "fall, no injury" based on the nurses' assessment of the patient and the situation.

Physician #4 stated they relied on RNs to conduct a thorough assessment to rule out injury as this could otherwise result in a delay in care. They stated patient falls created a risk for subdural hematomas which could be life-threatening, fractures, untreated pain, and vascular (vessels containing blood) injuries which could decrease blood flow to a limb. Physician #4 also stated many patients at the facility were on blood thinners which created an additional risk for injury.