HospitalInspections.org

Based on observation, interview and policy review, the facility failed to ensure a safe environment when a couch was placed in the Geriatric Behavioral Health Unit (GBHU) seclusion room, as a bed for geropsychiatric patients. This failure placed all patients at risk for an unsafe environment and had the potential to lead to injury and/or death. The facility census was 12, with all patients on the GBHU.

This deficient practice resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient's Rights.

Based on observation, interview, and policy review the facility failed to ensure a safe environment, when a couch was placed in the Geriatric Behavioral Health Unit (GBHU) seclusion room for patients to sleep on, which posed a risk to geriatric patients. Thus failure placed all patients at risk for an unsafe environment and had the potential to lead to injury and/or death. The facility census was 12, with all patients on the GBHU.

Findings included:

1. Review of the facility's policy titled, "Safety Overview," dated 04/2015, showed that geriatric patients' physical care should be as high a priority as their psychiatric care.

Observation on 11/05/18 at 2:30 PM, in the GBHU seclusion room, showed a couch in the room to use as a bed. The patients on the unit were elderly, ranging in age from 56 years old to 83 years old and had difficulty walking and bending, and eight patients were documented as a high fall risk.

During an interview on 11/05/18, Staff A, GBHU Nurse Manager, stated that the couch had been moved into the seclusion room just that day. He stated that he didn't know why and up until then, there had been nothing in the room for a patient to sleep on.

During an interview on 11/05/18 at 3:40 PM, Staff E, Chief Nursing Officer (CNO), stated that the bed situation for the GBHU seclusion room had been discussed in department leader morning meetings, but no bed had been chosen to put in the seclusion room.

During an interview on 11/05/16 at 3:55 PM, Staff J, Chief Executive Officer (CEO), stated that a previous Plan of Correction, with a correction date of 10/10/18, included that the facility would provide a bed in the GBHU seclusion room. He stated that as far as he knew, the State Agency had not been informed of the inability to fulfill the Plan of Correction. He stated that several different types of beds had been proposed but he did not like any of them for various reasons, and he was not aware that a couch had been moved into the GBHU seclusion room.

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed their policy when staff failed to perform a fall risk assessment after a change in cognition, change in ambulation/gait or fall for one discharged patient (#7) of one discharged patient and for two current patients (#2 and #4) of two current patients reviewed, who were at high risk for falls on the Geriatric Behavioral Health Unit (GBHU). This had the potential to lead to possible injury and/or death and could affect all patients on the GBHU. The facility census was 12, with all patient on the GBHU.

The severity and cumulative effect of these failures resulted in the facility being out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

Based on observation, interview, record review and policy review, the facility failed to ensure staff followed their policy when staff failed to perform a fall risk assessment after a change in cognition, change in ambulation/gait or fall for one discharged patient (#7) of one discharged patient, and for two current patients (#2 and #4) of two current patients reviewed that were at high risk for falls on the Geriatric Behavioral Health Unit (GBHU). This had the potential to lead to possible injury and/or death and could affect all patients on the GBHU. The facility census was 12, with all patients on the GBHU.

Findings included:

1. Review of the facility's policy titled, "Fall Assessment," dated 07/2016 showed:
- Definition: Fall, a person unintentionally and abruptly goes from a standing, sitting, or lying position to a lower level. Patients who are assisted to the floor by staff (and would have fallen without staff's assistance) will also be identified as a fall.
- Fall risk (patients) will be identified by bracelet.
- Patients are evaluated for risk for falls continually throughout treatment for development of new risk factors: changes in cognitive level; change in ambulation/gait; and after a fall.

Review of discharged Patient #7's Psychiatric Evaluation dated 10/03/18 showed that the patient had a past medical history of being legally blind (which placed him at greater risk for falls).

Review of the Patient Flowsheet Report - Fall Assessment (Fall Risk Assessment Tool)
dated 10/03/18 showed staff assessed the patient with a fall risk score of greater than 13 points (a score of greater than 13 total points indicated the patient was a "high fall risk"). Staff assessed the patient at greater than 13 total points throughout his stay from admission on 10/03/18 to discharge on 10/20/18.

Review of Patient Care Notes showed that:
- On 10/12/18 at 11:04 PM, the patient had a difficult time standing, bearing weight and ambulating (indicating a change in his usual ability to stand, bear weight and walk).
- On 10/13/18 at 1:31 PM, the patient was confused, disoriented and ambulated with a "shuffled" gait (change in cognition, ambulation and gait).
- On 10/13/18 at 10:31 PM, the patient attempted to get out of the reclining chair (a medical reclining chair with wheels) by himself and because the brakes were unlocked the chair began to slide out from under him. A Patient Care Technician (PCT) was able to grab the patient and lower him to the floor.
- On 10/16/18 at 7:48 PM the patient stood up out of the reclining chair and fell to the floor onto his coccyx (tailbone) and hit the right side of his face on the chair.
- On 10/20/18 at 4:39 PM, the patient fell head first onto the floor and obtained a red raised area on the top of his skull (head) that measured 9.6 centimeters (cm, metric unit of length) by 9.1 cm. Within the area was a "golf ball" sized blanched (turn white in color) area with a blue hue (bruise). The patient was alert, attentive and confused as normal (the patient experienced episodes of confusion at times). The physician was notified and ordered a Computed Tomography Scan (CT scan, x-ray testing that produces images of the body using those x-rays and a computer) of the head.
- On 10/20/18 at 5:44 PM, the emergency room physician notified nurse that the patient had a cervical fracture (broken neck).

Review of the Diagnostic Imaging Report dated 10/20/18, showed an acute (recent occurrence) fracture which involved the right lateral mass cervical vertebrae (C1, small bones in the neck that support the head).

Review of the Patient Flowsheet Report - Fall Assessment showed that staff did not document that they performed a fall risk assessment after the patient experienced difficulty standing, bearing weight and ambulating on 10/12/18; did not document that they performed a fall risk assessment after the patient experienced a change in cognition and had a "shuffled" gait on 10/13/18; and did not document that they performed a fall risk assessment after the patient fell down onto the floor on 10/16/18. Staff documented on the Patient Flowsheet Report - Fall Assessment on 10/12/18, 10/13/18 and 10/16/18 that "NO," the patient's fall status did not change in the last 24-hours (even though the patient experienced changes in his cognitive status, changes in ambulation/gait and fell onto the floor).

During an interview on 11/06/18 at 3:28 PM, Staff H, Registered Nurse (RN), stated that she worked on 10/16/18 when Patient #7 fell. Staff H stated that she did not perform a fall risk assessment after the patient fell. Staff H stated that the Patient Flowsheet Report - Fall Assessment question, "Has the patient fall status changed in the last 24-hours," needed to be answered "yes," since the patient had fallen, however, it was answered "no" and did not reflect the patient's fall. Staff H stated that she did not review or update the patient's fall prevention interventions or implement new interventions to prevent further falls and/or injury after the patient's fall on 10/16/18.

During an interview on 11/06/18 at 3:59 PM, Staff L, RN, stated that she worked when Patient #7 fell on 10/20/18. Staff L stated that after a patient had a fall or if a patient was lowered to the floor by staff, staff were to perform a fall risk assessment. Staff L stated that the Patient Flowsheet Report - Fall Assessment question, "Has the patient fall status changed in the last 24-hours," needed to be answered "yes" instead of "no," since the patient had indeed experienced a fall on 10/20/18. Staff L stated that after a fall, the patient's fall prevention interventions needed to be reviewed and updated with new interventions implemented to prevent further falls and/or injury.

2. Review of current Patient #4's Psychiatric Evaluation dated 10/18/18 showed the patient was admitted to the facility with threats to hurt herself by throwing herself onto the floor to cause head injury. The patient was assessed to have an unsteady gait.

Review of the Patient Flowsheet Report - Fall Assessment dated 10/18/18 showed staff assessed the patient with a fall risk score of greater than 13 points.

Review of Patient Care Notes showed that:
- On 10/25/18 at 7:35 PM, the patient wanted to get up out of the reclining chair and fell at 10:00 AM, with bruising that showed up after the fall on the left hip and left elbow. The patient fell again at 5:15 PM, when he "slid" out of the reclining chair.
- On 10/27/18 at approximately 11:35 AM, the patient fell to the floor . The patient struck her face on the floor and obtained a small split to her lip, had a nose bleed and contusion (bruise) to her right forehead that measured 5.3 cm by 6.4 cm. The emergency room physician came to the GBHU and examined the patient. An order was received to monitor the patient for altered mental status.
- On 10/27/18 at 7:04 PM, the patient had significant bruising to her face.
- On 10/27/18 at 11:23 PM, the patient's right side of her forehead was swollen, bruised and red. The patient's right eye was swollen and purple. The patient was taken for a CT scan, was seen by a physician and no facial fractures were noted.

Review of the Patient Flowsheet Report - Fall Assessment showed that staff did not document that they performed a fall risk assessment after the patient fell two times on 10/25/18, and did not document that they performed a fall risk assessment after the patient fell and hit her face on the floor 10/27/18. Staff documented on the Patient Flowsheet Report - Fall Assessment on 10/25/18 and 10/27/18 that "NO," the patient's fall status did not change in the last 24-hours (even though she experienced two falls on 10/25/18 and fell and hit her face on the floor on 10/27/18).

During an interview on 11/07/18 at 10:10 AM, Staff D, PCT, stated that staff referred to the white eraser board or non-skid sock color to identify what fall risk category patients were assessed.

Observation on 11/05/18 at 2:45 PM showed Patient #4 sat in the day room reclined back in a reclining chair. The patient had an approximate quarter sized faded reddish colored bruise under each eye and an approximate half dollar sized faded reddish colored bruise on her right forehead. The patient did not have on a bracelet to indicate she was assessed at high risk for falls. The white eraser board located on the unit did not have a red star next to the patient's name to indicate she was assessed at high risk for falls.

During an interview on 11/05/18 at 3:27 PM, Staff I, PCT, stated that Patient #4 did not have a fall bracelet on and the white easer board did not have a "red" star by her name to indicate she was assessed at high risk for falls.

During an interview on 11/07/18 at 2:18 PM, Staff M, Licensed Practical Nurse (LPN), stated that she worked on 10/25/18 when Patient #4 fell twice during her shift. Staff M stated that she did not do a fall risk assessment after the patient fell twice. Staff M stated that she was not trained or educated during her orientation to do a fall risk assessment after a patient had a fall. Staff M stated that she did not review or update the patient's fall preventions or implement additional preventive interventions to protect the patient from additional falls and/or injury.

3. Review of current Patient #2's Psychiatric Evaluation dated 10/17/18 showed the patient had a past medical history of being legally blind (which placed her at greater risk for falls).

Review of the Patient Flowsheet Report - Fall Assessment dated 10/18/18 showed staff assessed the patient with a fall risk score of greater than 13 points.

Review of Patient Care Notes showed that:
- On 10/24/18 at 7:49 PM, the patient placed herself onto the floor in the dayroom (the EMHR did not state where the patient was before she placed herself on the floor, for example, her wheelchair, reclining chair or sofa).
- On 10/30/18 at 6:16 PM, the patient "toppled" herself out of the reclining chair this morning and was found lying on her right side on the floor.
- On 11/03/18 at approximately 8:50 AM, the patient "slid" herself purposefully onto the floor and crawled around as if she was looking for something (the EMHR did not state where the patient was before she placed herself onto the floor, for example, her wheelchair, reclining chair or sofa).

Review of the Patient Flowsheet Report - Fall Assessment dated 10/24/18, 10/30/18 and 11/03/18 showed staff did not document that they performed a fall risk assessment after the patient placed herself onto the floor two times and after she was found lying on the floor

During an interview on 11/06/18 at 10:04 AM, Staff A, RN, GBHU Nursing Manager, stated that a fall risk assessment should be completed by the nurse after any fall.

During an interview on 11/06/18 at 2:41 PM, Staff G, RN, Quality Risk Manager, stated that staff were to mark "yes" on the Patient Flowsheet Report - Fall Assessment, if a patient experienced a fall or was assisted to the floor by staff.

During an interview on 11/07/18 at 3:23 PM, Staff A, RN, GBHU Nursing Manager, stated that he expected staff to follow the facility's policy, perform a fall risk assessment after a patient experienced a fall, review/update fall prevention interventions and implement additional interventions if needed to prevent additional falls and/or injury.

During an interview on 11/07/18 at 4:00 PM, Staff E, RN, Chief Nursing Officer (CNO), stated that she expected staff to perform a fall risk assessment per the facility's policy after a patient had a change in cognition or change in ambulation/gait, and after a fall. Staff E stated that she expected staff to review and update if needed, fall prevention interventions to protect patients from future falls and/or injury.

Staff failed to protect discharged Patient #7, current Patient #4 and #2 from additional falls and injury when they did not perform a fall risk assessment after the patients experienced a change in cognition, change in ambulation/gait or after a fall. Staff failed to review, update or implement additional preventive fall interventions to protect the patients and to prevent additional falls and/or injury.