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Based on document review, observation, and interview, it was determine the Hospital failed to appropriately evaluate on an ongoing basis to ensure patients were cared for in accordance with accepted standards of nursing practice and hospital policy. Therefore, the Condition of Participation, 42 CFR 482.23, Nursing Services was not met.

Findings include:

1. The hospital facility failed to ensure that the nurse completed a post-fall assessment after a patient fall. (See A392)

2. The Hospital failed to ensure fall precautions were in place for high fall risk patients. (See A396)

The Immediate Jeopardy was identified on 10/08/2024, at 42 CFR 482.23, Nursing Services due to the Hospital's failure to: ensure fall precautions were in place for high fall risk patients. Eight of Eight observed patients for high fall risk and 1 of 1 sentinel event for falls. Pt #1's bed alarm sounded, and Pt #1 was found on the floor and sustained a head laceration and subdural hematoma (brain bleed). Pt #1 was ultimately transferred to another hospital for a higher level of care.

Based on document review and staff interview, it was determined for 1 of 3 (Pt #9) patient fall event records reviewed, the hospital facility failed to ensure that the nurse completed a post-fall assessment after a patient fall.

Findings include:
1. On 10/7/24 at approximately, 1:30 PM, (Pt #9's) record was reviewed. Pt #9 was admitted to the 6th floor Medical/surgical unit on 9/5/24 with a diagnosis of weakness. Pt #9's record included a nursing note on 9/10/14 at 6:30 am which stated, "Per night shift nurse, patient had a fall through the night, the bed does not have an alarm, so patient called and stated that (Pt #9) needed help getting back up. Patient was then placed back in bed and they placed a chair alarm under (Pt #9). MD and (family) was notified. MD ordered x-ray of pelvis and hip."

2. The Facility policy titled "HSHS Falls Prevention and Management (revised January 1, 2024)" was reviewed on 10/08/24 at approximately 3:00 PM. The policy stated, " ... B. POST-FALL MANAGEMENT: ... 2. The patient is assessed for injuries. 3. The patient's injuries are addressed immediately to prevent further patient harm ... C. DOCUMENTATION POST-FALL: a. Patient location and appearance at time of discovery. b. Patient response to event. ..."

3. An interview was conducted with the Nurse Educator (E #6) on 10/08/24 at approximately 11:30 AM. E #6 verbally agreed the record lacked a post fall assessment and stated, "there should have been a post-fall assessment documented."

Based on observation, document review and interview, it was determined for 8 of 8 (Pt # 3, #4, #5, Pt #6, Pt #11, P#12 and Pt #13) observations and 1 of 1 (Pt #1) sentinel event patient records, the Hospital failed to ensure fall precautions were in place for high fall risk patients. Pt #1's bed alarm sounded, and Pt #1 was found on the floor and sustained a head laceration and subdural hematoma (brain bleed). Pt #1 was ultimately transferred to another hospital for a higher level of care.

Findings include:

1. An observational tour was conducted on 10/7/24 of the 6th floor Medical/Surgical unit with RN/Educator (E #6) from 10:25 AM to 11:00 AM.

The following observations were noted:

- Room 631- the fall indicator light outside of the patient's room was not illuminated. Pt #3 was observed sitting in bed, but bed alarm was not on. Pt #3 was admitted to the Hospital on 10/3/24 for hip and arm pain. Pt #3's Morse Fall Score/PA Score on 10/7/24 was 95 (score greater than 45 indicates patient is a high fall risk).

- Room 630 - the fall indicator light outside of the patient's room was not illuminated. Pt #4 was observed sitting in bed, but bed alarm was not on. Pt #4 was admitted to the Hospital on 10/2/24 for groin pain, constipation, and urinary symptoms. Pt #4's Morse Fall Score/?PA Score on 10/7/24 was 75.

- Room 614 - Pt #5 was observed sitting in bed, but bed alarm was not on. Pt #5 was admitted to the Hospital on 10/5/24 for weakness. Pt #5's Morse Fall Score/PA Score was noted on 10/7/24 and was 75.

- Room 605 - Pt #6 was observed sitting in a chair, no chair alarm was in place. Pt #6 was admitted to the Hospital on 10/5/24 with a diagnosis of pneumonia. Pt #6's Morse Fall Score//PA Score on 10/7/24 was 85.

- Room 608 - the fall indicator light outside of the patient's room was not illuminated. Pt #7 was admitted to the Hospital on 10/6/24 with a diagnosis of sepsis. Pt #7's Morse Fall Score//PA Score on 10/7/24 was 75.

- Room 629 - the fall indicator light outside of the patient's room was not illuminated. Pt #11 was observed sitting in bed and bed alarm was not on. Pt #11 was admitted to the Hospital on 10/6/24 with a diagnosis of acute kidney injury and urinary tract infection. Pt #11's Morse Fall Score//PA Score on 10/7/24 was 85.

- Room 606 - During the observational tour Pt #12 was observed sitting in bed and bed alarm was not on. Pt #12 was admitted to the Hospital on 10/3/24 with a diagnosis of heart failure. Pt #12's Morse Fall Score//PA Score on 10/7/24 was 50.

- Room 609 - the fall indicator light outside of the patient's room was not illuminated. Pt #13 was observed sitting in bed and bed alarm was not on. Pt #13 was admitted to the Hospital on 10/3/24 with a diagnosis of left total knee revision. Pt #13's Morse Fall Score//PA Score on 10/7/24 was 60.

Observations confirmed with Registered Nurse Educator (E #6) and E #6 verbally agreed the patients were high fall risk and the fall interventions were not in place.

2. The policy titled "HSHS Falls Prevention and Management (Rev 01/01/2024)" was reviewed. The policy stated, " ... 1. Prevention: 1. Fall Risk Assessment: ... 2. The patient's risk assessment is performed and scored using the evidence-based risk assessment tools and may include but is not limited to ... a. Upon admission to the hospital or ED. b. Once per shift (admitted patients) ... 3 ... a. High Risk Fall prevention interventions will be implemented for patients with fall risk score that fall into the high-risk category ... ii. Implement, at a minimum, fall risk interventions as outline in the EMR (Electronic Medical Record) ... "

3. The EMR "Fall Risk Interventions" flowsheet was reviewed and indicated, "Patient Morse/Fall Risk PA Score of 45 or higher is HIGH RISK; implement applicable individual and ALL HIGH RISK interventions."

4. Fall Prevention education was reviewed and included, "High Fall Risk Interventions: Fall risk care plan, fall risk visual indicator outside the door, bed and chair exit alarms, yellow fall risk charm on ID band, non-skid socks ..."

5. Pt #1's record was reviewed throughout the survey. Pt #1 arrived by ambulance to the Emergency Department (ED) on 8/19/24 at 8:05 AM with a chief complaint of "Palpitations (feeling of heart pounding/racing) and shortness of breath." A cardiology consult was conducted at 12:12 PM and stated, " ... Physical Exam: ... Neurological: Mental Status: (Pt #1) is alert. Psychiatric: Cognition and Memory: Cognition is impaired. Memory is impaired." Pt #1 was admitted to the 6th floor at 3:15 pm. Initial inpatient Fall Risk Assessment at 3:55 pm completed by Registered Nurse (E #7) indicated a Morse Fall Risk Score of 85 (Score of 45 or greater is High Risk). Pt #1's record stated, "High Risk Fall Interventions: Initiate Fall Risk Care Plan." At 7:00 pm, Licensed Practical Nurse (E #8) documented a "Shift Assessment" which included, "Neurological: ... Alert, Oriented to person, Cognition: Impulsive; Poor Judgement; Poor safety awareness; Poor attention/concentration ... Fall Risk Interventions: Standard Fall Prevention: ... Rounding Q (every) 2 hrs (hours); Individualized Fall Interventions: ... Place patient for visualization... Elimination Q 2 hrs ..." A nursing note at 10:02 pm stated, "Patients bed alarm went off and writer went to find patient on floor with blood coming from back of head. Patient assessed and was assisted back to bed and hospitalist called at this time." A "Plan of Care" by Nurse Practitioner (NP - E #9) noted, "Notified by nocturnist at 10:02 pm that patient has suffered a fall ... Copious amounts of blood are on the floor and matted to (Pt #1)'s head. Per nursing report, patient was found laying on the floor. Stat Head CT[computed tomography scan] and C spine ordered. Head CT result showed acute right frontoparietal convexity extra-axial hematoma (right frontal head bleed) .... Called and discussed case with cardiologist in regards to coumadin reversal - recommends 5mg (milligram) oral Vitamin K ... Patient is restless. GCS[Glascow Coma Scale] 11. I called and spoke with (outlying hospital with higher level of care capabilities) ... Case presented to trauma surgeon. Read head CT report to the trauma surgeon ... Patient accepted for transfer for expert consultation of trauma surgery .... Patient to be Med-Evac to (other hospital) ... This patient had a high probability of imminent or life-threatening deterioration due to acute subdural hematoma ..."

Pt #1's record lacked initial fall interventions placed upon inpatient admission and lacked the 2-hour rounding required which would have indicated fall interventions that were in place when Pt #1 fell. Pt #1 was documented at 7:00 pm as "Impulsive; Poor Judgement; Poor safety awareness; Poor attention/concentration" with no change/modification in fall prevention interventions.

6. The Adverse Event and Sentinel Event logs were reviewed and included Pt #1's event. The "Moderate Risk Event" document was reviewed and stated, " ... Assessment- Opportunities: ... Intervention of rounding Q2 - no documentation of rounding completed within 2 hours of fall .... Recommendation: ... Re-education on purposeful and appropriate documentation in tier 1 huddles (purposeful rounding tip sheet) annually ... Due Date 11/15/2024"

7. An interview was conducted with Medical/ Surgical Unit Nurse Manager (E #3) on 10/08/2024 at approximately 10:30 am. E #3 stated, "We just started to roll out the education last week. We do not have formal sign in sheets to indicate who all has received the education."