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Based on policy and procedure review, medical record review, observation and staff interview, the nursing staff failed to ensure falls interventions were in place for patients identified as "High Risk" for falls in 6 of 13 Gero Psych Behavioral Health (BH) patients (Patient #3 #11, #12, #14, #15 and #16).

The findings include:

Review on 12/15/2016 of the facility's policy and procedure, "Falls Assessment, Prevention and Management-Adult Inpatients" (revised 08/20/2015) revealed, a "Morse Fall Scale" ... Low/Moderate Risk 0-44 Implement low to moderate Risk Fall Prevention Interventions High risk 45 and higher Implement High Risk Fall Prevention Interventions ... BEHAVIORAL HEALTH Patients fall interventions include: 1 Utilize non-skid footwear for patient 2. Bed in low position with brakes locked 3. Safety rounds performed every 15 minutes 4. Reinforce BH fall risk prevention strategies with patient/and or support person(s) HIGH fall risk BH patients only; 5. Apply yellow armband to patient; GERO-PSYCH BEHAVIORAL HEALTH patients High Fall Risk interventions include; Implement all 5 of the BH fall interventions 6. Assure assistive devices are available as needed 7. Assist with elimination and exercise as needed 8. Bed in low position with brakes locked, 2 upper rails raised 9 call bell and patient items within reach 10. Staff remain within visual, auditory, or at arms-length during toileting 11. Bed/chair alarms on at ALL times. ..."

Review on 12/15/2016 of the facility's policy and procedure, "Clinical Alarms" (revised Jan16) revealed, "...2. Alarms are sufficiently audible and/or visible with respect to distances and competing distractions within the unit. ...a. User Responsibilities- b. Assure alarms ... are effective, audible and/or visible before use. ..."

1. Review of the closed medical record on 12/16/2016 for Patient #3 revealed he was admitted by Involuntary Commitment (IVC) on 09/10/16 to the Gero (geriatric) Psych (psychiatric) Behavioral Health Unit with a diagnosis of brief Psychotic disorder (mental problem) and " Active Hospital Problems " ARF (acute renal failure), CAD (Coronary Artery Disease) CHF (congestive heart failure) COPD (chronic obstructive pulmonary disease, Hypothyroid (low thyroid function), Gout (bone disease) and Arthritis (bone disease). History and Physical revealed the patient had had an unsteady gait and was confused. Review of a " BH Adult Daily Assessment " revealed on admission, Patient #3 had a documented fall score of 50. Review revealed on 09/14/2016 at 1109 Patient #3's fall score was 30. At 1828 a "Nurses Note" revealed, "... about 1700 ... his gait was unsteady; staff attempted to help pt (patient); he became very angry; very difficult to redirect; pt pushing and hitting at staff; ..." Further review of a "BH Adult Daily Assessment" revealed at 1940 Patient #3's Morse fall score was 30. Further review revealed Patient #3's status was elevated to a High Fall Risk per Nursing Judgement (nursing assessment of patient ' s fall risk) to and "All (fall) Interventions performed". At 2130 records revealed a "Nursing Note" stating, "At 1945 patient was in a recliner in day room with a lap belt in place. Staff turned their attention towards him and witness he had slipped out from under the lap belt and was attempting to stand next to the chair. He then lost his balance and fell to the floor... Patient continues on high risk for falls ..." Review of the "BH Adult Daily Assessment" revealed at 1950 Patient #3's Morse fall score was 55. Further review revealed Patient #3's status was elevated to a High Fall Risk per Nursing Judgement and all fall interventions performed. Review of "Adult Post Fall Safety Huddle" report revealed patient was at risk for fall, chair alarm was on as indicated by the fall risk and non-skid footwear were in place. Review revealed no documentation of the chair alarm sounding as a result of the patient exiting the chair.

Review of a "BH Adult Daily Assessment" revealed the Patient #3 had a fall score of sixty- five documented at 0830 on 10/08/2016. Review of a "Nursing Note" at 1050 revealed, "pt drowsy this AM, resting comfortably in bed, turning self, no s/s of distress. Pt found at 9:55am on floor in room by bathroom, on left side, unwitnessed fall. [Staff name] near room and responded. RN (registered nurse) and NP (nurse practitioner) assessed pt, VS taken, see flowsheet. Pt had scratch with a bump on left temple. Neck brace placed and place on back board.... Pt taken for CT of head and spine. .. All medications not given d/t (due to) fall, NP aware." Further review of an "Interim Progress Note" at 1141 revealed the patient was seen for a partially unwitnessed fall. Housekeeping requested the staff to come assist patient who had fallen to the floor. Patient was found outside the bathroom with on his left side holding the left side of his head. ... Side rails up x 3 on bed with bed alarm present but did not activate when patient got out of bed. ..." Further review revealed no documented "Adult Post-Fall Safety Huddle" report was available. Review revealed documentation the bed alarm was in place, but, did not alarm.


An interview on 12/13/2016 at 1410 with RN #1 revealed a patient identified with "High Risk Fall" precautions had a yellow wristband, were rounded on every 15 minutes, and had chair or bed alarms in place. Further interview revealed, "Almost all" patients were considered "high fall risk" because they took psychotropic drugs. The interview revealed when a chair or bed alarm went off the staff would "localize where the sounds come from" and "it was easy."

An interview on 12/145/2016 at 1455 with RN #2 revealed she recalled caring for Patient #3. Interview revealed "EVS" (environmental services) found the patient on the floor. Further interview revealed Patient #3 was not in direct view of unit staff. Continued interview revealed, "No bed alarm went off." The interview confirmed Patient #3's Morse score was sixty -five on 10/08/2016 at 0830. Further interview revealed, based on the Morse score of 65, the bed alarm should have been on, the bed should have been in low position, the side rails should have been up, every 15 minute rounding should have occurred by the nurse tech and hourly rounding should have occurred by the RN. The interview revealed RN #2 was in the room next door adjacent to Patient #3 when the incident occurred on 10/08/2016. The interview revealed RN #2 did not hear the bed alarm go off in while in the adjacent room. The interview revealed that a bed alarm could be heard up to "two rooms down", but RN #2 did not hear the alarm on 10/08/2016. RN #2 said there was no way to adjust the sensitivity on the bed alarm, they were pads placed under the patients back and buttocks and if the patient turned a certain way the alarm may not sound. Further interview revealed Patient #3's bed was in low position at the time of the fall.

An interview on 12/15/2016 at 1710 with AS (administrative staff) #1 revealed, there were questions as to whether there was a delay in the alarm sounding or a delay in the staff response to the alarm on 10/08/2016. Further interview revealed the alarm did not sound and there was concern about not hearing the alarm. The interview revealed all the batteries were changed on all of the portable chair alarms to ensure that they were functioning (no date provided). Continued interview revealed the older beds on the unit did not have alarms or they did not work, so the staff "did a good job" to create a barrier by placing portable chair alarms in their place. The interview revealed the portable chair alarms were checked at the beginning of each shift and the batteries were changed as needed. Interview revealed there was no routine schedule for changing the batteries on the chair alarms. Further interview revealed as a response to the incident on 10/08/2016, a rental agreement with a bed distributor was initiated which resulted in 27 new rental beds with alarms being placed on the BH unit. In addition, the facility had ordered 45 new replacement beds for the entire unit. Interview revealed there was no "Post Fall Huddle'' report found for the fall occurring on 10/08/2016

An interview on 12/13/2016 during the BH unit tour and on 12/15/2016 at 0900 with the AS #2 " All " patients that are identified as a "high fall risk" should have all on the interventions implemented. If the fall interventions were not in place, there should be a documented rationale as to why it was not implemented in the notes. Further interview revealed, the bed and chair alarms were not connected to the nurse call system. Continued interview revealed as a result of the incident that occurred on 10/08/2016 with Patient #3, the unit was having a new central call system installed which would allow the bed alarms to sound directly to the nurses ' station. In addition, the staff were now required to check all equipment at the beginning of each shift, if it did not work, the battery would be replaced or the piece of equipment would be taken out of service and replaced with a functioning piece of equipment.

Observation on 12/13/2016 at 1200-1500 during unit tour revealed patients in the day room with staff present. Observation revealed patients in their private room with and without direct observation. Further observation revealed a PCT performing a safety check on a chair alarm for a patient sitting in a chair in the dayroom. Observation revealed PCTs going in and out of patient rooms. Further observation revealed patients being reoriented and redirected. Unit observation revealed a clean unit with no obstacles or trip hazard in the hallways. Patient rooms were neat and tidy. Observation revealed silver hand bells being used as the call bell and portable chair alarms used on some of the patient beds for bed alarms.

2. Observation of Patient #11 on 12/13/2016 during a unit tour from 1200-1500 revealed she was in her assigned room laying in the bed. Observation revealed she was sleeping with the head of the bed elevated. Observation revealed Patient #11 was not in direct view of unit staff. Further observation revealed the bed alarm was not activated and a call bell on a bedside table that was not within arm 's reach. Review on 12/15/2016 of the open medical record for Patient #11 revealed she was admitted by IVC on 12/13/2016 with a diagnosis of auditory hallucinations, psychosis and aggression. Review revealed Patient #11's admitting Morse fall score on 12/13/20106 at 2005 was 30. Further review of the medical record revealed Patient #11's status was elevated to a High Fall Risk per Nursing Judgement and "All (fall) Interventions performed".

An interview on 12/13/2016 at 1430 during the BH unit tour with the AS #2 revealed, "All" patients that were identified as a "high fall risk" should have all on the interventions implemented. If the fall interventions were not in place, there should be a documented rationale as to why it was not implemented in the notes. The interview confirmed there was no documented rationale for not implementing all of the fall interventions indicated. Further interview revealed, the bed and chair alarms were not connected to the nurse call system, but, a new system was being purchased that would allow bed and chair alarms to be connected to the nurses call system. Further interview revealed the patient should have had a call bell at the bedside for use. The interview revealed a call bell was a required intervention for all patients including those patients identified as a "High Fall Risk".

3. Observation of Patient #12 on 12/13/2016 during a unit tour from 1200-1500 revealed he was in the dayroom in a recliner. Observation revealed the chair alarm was disconnected from the monitoring box. Observation revealed the monitoring box was sitting on the IV (intravenous) pole. Observation revealed RN #1 connected the box to the chair alarm pad and it sounded. Observation revealed RN #1 removed the box, left the dayroom and returned with another monitor box and connected it to the chair alarm pad. Further observation revealed Patient #12 was in direct view from the nurses ' station. Observation revealed the chair alarm was not connected to the patient for an undetermined amount of time.

Review on 12/15/2016 of the open medical record for Patient #12 revealed he was admitted by IVC on 12/02/2016 with a diagnosis of dementia with a behavioral disturbance. Review revealed Patient #12's admitting Morse fall score on 12/13/20106 at 2005 was 70. Further review Patient #12's Morse fall score on 12/15/2016 was 70. Review revealed Patient #12 was identified as a " high falls risk" patient.

An interview on 12/13/2016 at 1410 with RN #1 revealed the chair alarm was not functioning. The interview revealed the malfunctioning monitor box was replaced with a working box. The interview revealed RN #1 could not recall how long the patient was in the chair without a properly functioning chair alarm

An interview on 12/13/2016 at 1430 during the BH unit tour with the AS #2 revealed, "All" patients that were identified as a "high fall risk" should have all on the interventions implemented. If the fall interventions were not in place, there should be a documented rationale as to why it was not implemented in the notes. The interview revealed no documented rational for not implanting all of the fall interventions indicated. Further interview revealed, the bed and chair alarms were not connected to the nurse call system, but, a new system was being purchased that would allow bed and chair alarms to be connected to the nurse call system.

4. Observation of Patient #14 on 12/13/2016 during a Gero Psych BH unit tour from 1200-1500 revealed she was lying in the bed mumbling. Observation revealed four side rails up and the bed alarm was not activated. Observation revealed AS #2 assisted RN #1 with activating the bed exit alarm. Continued observation revealed she was in a patient room not in direct view of the unit staff. Further observation revealed RN #1 put the two bottom side rails down. Observation revealed all "High Fall Risk" interventions were not in implemented for Patient #14.

Review on 12/15/2016 of the open medical record for Patient #14 revealed she was admitted by IVC on 11/23/2016 with a diagnosis of Major Depression. Review revealed Patient #14's Morse fall score on 12/13/2016 at 0949 was 65. Review revealed every 15 minute safety checks were documented, but, no order for a physical restraint and no documentation of a patient or family request for the use of four side rails.

An interview on 12/13/2016 at 1400 with RN #1 revealed he was not sure who put all four side rails up. The interview revealed 4 elevated side rails was considered a restraint. Further interview revealed all four side rails were up for an undetermined amount of time. Further interview revealed there was no order for Patient #14 to be restrained and the two bottom side rails would be lowered.

An interview on 12/13/2016 at 1430 during the BH unit tour with the AS #2 revealed, "All" patients that were identified as a "high fall risk" should have all on the interventions implemented. If the fall interventions were not in place, there should be a documented rationale as to why it was not implemented in the notes. Interview with AS #2 revealed RN #1 was not sure how to use the bed exit alarm because there are three different bed models on the unit and the bed exit alarm activation is different for each unit. The Interview revealed all staff including RN #1 were reeducated on restraint usage and on use of the bed exit alarms.

5. Observation of Patient #15 on 12/13/2016 during a unit tour from 1200-1500 revealed she was sleeping in her bed. Observation revealed a bedside table with no call bell on it. Observation revealed no call bell within arm's reach of the patient. Further observation revealed RN #1 left the patient room and returned with a call bell for Patient #14. Observation revealed she was not in direct view of the unit staff. Observation revealed Patient #14 had no call light available for use.

Review on 12/15/2016 of the open medical record for Patient #15 revealed she was admitted by IVC on 12/09/2016 with a diagnosis of Psychosis and dangerous behavior, and dementia with behavioral disturbance. Review revealed Patient #15's Morse fall score on admit was 30. Review revealed Patient #15's Morse score was 30 on 12/13/2016. Further review revealed Patient #3's status was elevated to a "High Fall Risk per Nursing Judgement".

Interview on 12/13/2016 at 1430 with RN #1 revealed there was no call bell at Patient # 14's bedside. Interview revealed a call light was to be retrieved. The interview revealed RN #1 did not know how long patient #14 was without a call bell.

An interview on 12/13/2016 at 1430 during the BH unit tour with the AS #2 revealed, "All" patients that were identified as a "high fall risk" should have all on the interventions implemented. If the fall interventions were not in place, there should be a documented rationale as to why it was not implemented in the notes. Further interview revealed the patient should have had a call bell at the bedside for use. The interview revealed a call bell was a required intervention for all patients including those patients identified as a "High Fall Risk".

6. Observation of Patient #16 on 12/13/2016 during a unit tour from 1200-1500 revealed she was sitting in a chair in the dayroom. Continued observation revealed the patient was in view of the BH unit staff. Observation revealed no chair alarm in use.

Review on 12/15/2016 of the open medical record for Patient #16 revealed she was admitted by IVC on 11/16/2016 with a diagnosis of Dementia and behavioral disturbance. Review revealed Patient #16's Morse score was 65 on 12/13/2016.

An interview on 12/13/2016 at 1430 during the BH unit tour with the AS #2 revealed, "All" patients that were identified as a "high fall risk" should have all on the interventions implemented. If the fall interventions were not in place, there should be a documented rationale as to why it was not implemented in the notes.
NC00122210

Based on review of the policy and procedure, observation and staff interview, the nursing staff failed to obtain and order and monitor a restrained patient in one of one restrained patients observed (Patient #14).

The findings include:

Review on 12/15/2016 of the policy and procedure "Restraints and Seclusion" (revised Mar12) revealed, "... 3. Sequence of least to most restrictive restraints: a. Siderails X 4 - appropriate safety measures/interventions (including gap closure devices) will be considered to prevent patient injury; ... 4. Order required- a. Individual order required- The use of restraint or seclusion must be in accordance with the individual order of a practitioner who is responsible for the care of the patient. ... 6. Monitoring ... documented every 2 hours ..."

Observation of Patient #14 on 12/13/2016 during a Gero (geriatric) Psych (psychiatric) BH unit tour from 1200-1500 revealed she was lying in the bed mumbling. Observation revealed four side rails up and the bed alarm was not activated. Observation revealed AS (administrative staff) #2 assisted RN (registered nurse) #1 with activating the bed exit alarm. Continued observation revealed she was in a patient room and not in direct view of the unit staff. Further observation revealed RN #1 put the two bottom side rails down. Observation revealed all "High Fall Risk" interventions were not in implemented for Patient #14. Observation on 12/15/2016 during unit tour revealed Patient #14 in the bed. Observation revealed four side rails up. Further observation revealed a RN put the two bottom siderails down.

Review on 12/15/2016 of the open medical record for Patient #14 revealed she was admitted by IVC on 11/23/2016 with a diagnosis of Major Depression. Review revealed Patient #14's Morse fall score on 12/13/2016 at 0949 was 65. Review revealed no order for a physical restraint and no documentation of a patient or family request for the use of four siderails.

An interview on 12/13/2016 at 1400 with RN #1 revealed he was not sure who put all four side rails up. The interview revealed four elevated side rails was considered a restraint. An interview on 12/13/2016 at 1400 with RN #1 revealed he was not sure who put all four side rails up. The interview revealed four elevated side rails was considered a restraint. Further interview revealed there was no order for Patient #14 to be restrained and the two bottom side rails would be lowered.

An interview on 12/13/2016 at 1430 during the BH unit tour with the AS #2 revealed, "All" patients that were identified as a "high fall risk" should have all on the interventions implemented. If the fall interventions were not in place, there should be a documented rationale as to why it was not implemented in the notes. The interview revealed the use of four side rails is considered a restraint and required an order and monitoring. Further interview with AS #2 revealed RN #1 was not sure how to use the bed exit alarm because there are three different bed models on the unit and the bed exit alarm activation is different for each unit. The Interview revealed all staff including RN #1 were reeducated on restraint use and how to use the bed exit alarms.
NC00122210