HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to ensure:
- A patient's Power of Attorney (POA, someone legally designated to make decisions about a patient's healthcare options, who is not able to make decisions on their own) was notified of an injury from a fall and transfer to another hospital for one discharged patient (#5) of two patients reviewed. (A-0117)
- Staff followed their policies and procedures to prevent falls for patients identified as high fall risk for two current patients (#7 and #9) and three discharged patients (#4, #5 and #23) of five patients reviewed. (A-0144)
- Six of six designated psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) had psychiatric safe beds, in two of two Emergency Departments (ED) observed. (A-0144)
- There was designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) observation for all patients in two of two EDs. (A-0144)

These failed practices resulted in a systemic failure and non-compliance with 42 CFR 482.13 Condition of Participation (CoP) of Patient's Rights. The hospital's census was 155.

Please refer to A-0117 and A-0144.


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Based on interview, record review and policy review, the hospital failed to notify a patient's Power of Attorney (POA, someone legally designated to make decisions about a patient's healthcare options, who is not able to make decisions on their own) of an injury from a fall and transfer to a different hospital for one discharged patient (#5) of two patients reviewed. These failures had the potential to affect the quality of care and safety of all patients.

Findings included:

Review of the hospital's policy titled, "Informed Consent Policy," dated 07/23/25, showed patients had the right to make informed decisions about their treatment. Providers communicated adequate information to patients or their representatives in order to make informed decisions regarding their treatment. All significant medical information was disclosed, by the provider, prior to treatment. That information included the nature of the patient's condition, the individuals who provided treatment, and an opportunity to ask questions. The provider ensured the patient (or representative) was appropriately informed and consented to the specific treatment.

Review of Patient #5's medical record, dated 09/23/24, showed:
- She was an 84-year-old who presented in the Emergency Department (ED) for gastrointestinal hemorrhage (excessive bleeding that starts in the intestinal tract).
- On 09/24/24 at 12:30 AM, ED notes showed Patient #5 fell trying to get out of bed.
- At 12:33 AM, a computerized tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) showed bones in her left eye socket were broken with possible other eye structures involved.
- At 9:22 AM, she was transferred to Hospital C, General Acute Care for a higher level of care due to the left eye socket injury.
- At 9:25 AM, staff attempted to call the POA but reached the answering machine.
- At 9:26 AM, staff called the number in the chart and was told it was the wrong number and they were not her family.
- The patient's POA was not notified of the fall with injury or the change to her plan of care to transfer to Hospital C, General Acute Care Hospital.

Review of Patient #5's medical record from Hospital C, dated 09/24/24, showed the POA used the same phone number for emergency contact information.

During an interview on 07/30/25, at 1:34 PM, Staff LL, Chief Nursing Officer (CNO), stated that family were to be notified if a patient fell, regardless of the time of the fall. She expected documentation of the fall and the family notification. If a confused patient was transferred, family was notified of the transfer. In the event the family could not be reached, that report was given to the receiving hospital.

During a telephone interview on 07/30/25, at 2:00 PM, Staff NN, Registered Nurse (RN), stated that family were to be called, even in the middle of the night, if a patient fell.

During an interview on 07/29/25, at 10:11 AM, Staff Q, RN, stated that he called emergency contacts or representatives when ED staff needed consent from a confused patient.

During an interview on 07/29/25, at 10:24 AM, Staff R, RN, stated that ED patient charts highlighted their representative when applicable. If the patient did not have a representative documented, the chart prompted nurses to ask the patient about their agent information.

Based on observation, interview, record review and policy review, the hospital failed to ensure:
- Staff followed their policies and procedures to prevent falls for patients identified as high fall risk for two current patients (#7 and #9) and three discharged patients (#4, #5 and #23) of five patients reviewed.
- Six out of six designated psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) in two of two Emergency Departments (ED), had psychiatric safe beds.
- There was designated continuous telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) observation for all patients in two of two EDs.
These failures had the potential to affect the quality of care and safety of all patients.
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Findings included:

Review of the hospital's undated document titled, "Incident Reports (a staff report of an unexpected occurrence)," showed 90 falls occurred in the hospital within the previous six months.

Review of the hospital's policy titled, "Fall Prevention and Management," dated 05/14/25, showed based on the patient's identified risk factors and specific circumstances, a bed alarm/chair alarm may be applied as an additional fall prevention intervention. Unit specific signage may be utilized to assist staff and others coming on to the unit to identify high fall risk patients.

Observation on 07/29/25 at 9:00 AM, on the 7th floor, showed Patient #9 was identified as a fall risk, with a yellow fall risk bracelet and fall risk signage on his room door. His bed alarm was not activated.

Review of Patient #9's medical record showed:
- He was 72-year-old admitted on 07/26/25 for chronic obstructive pulmonary disease (COPD, a lung disease that prevents normal airflow and breathing) exacerbation (increase in symptoms).
- On 07/29/25, nursing documented a Morse Fall Risk Screening/Assessment (a method of assessing a patient's likelihood of falling) which showed he was a high fall risk.
- Interventions aimed at fall prevention included, a bed alarm, yellow socks, a yellow fall risk bracelet and use of a walker with ambulation.

Observation on 07/28/25 2:30 PM, on the 7th floor, showed Patient #7 was lying in bed without his bed alarm activated.

Review of Patient #7's medical record dated 07/18/25, showed:
- He was a 79-year-old admitted for a left hip fracture.
- On 07/28/25, a Morse Fall Risk Assessment showed he was a high fall risk.
- Documented nursing interventions for fall prevention included, a yellow fall risk bracelet, yellow fall risk socks, use of a gait belt with ambulation and a bed/chair alarm was in place.

Review of the hospital's document titled, "Current Summary Fall Event (1160883)," dated 07/10/25, showed at 7:45 AM, Patient #23 was found face down on the floor and bleeding from his forehead. The primary registered nurse (RN) reported all fall interventions were in place; however, after she turned the patient, she forgot to turn the bed alarm back on.

Review of Patient #23's medical record dated 07/01/25, showed:
- He was an 86-year-old admitted for a complex percutaneous coronary intervention (PCI, a heart procedure to open blocked arteries).
- On 07/02/25, an order was placed for fall precautions due to a Morse Fall Risk Screening/Assessment score greater than 45.
- On 07/10/25 at 8:45 AM, the fall event note showed he had a fall and the additional actions the team took included to ensure the bed alarm was engaged after each turn.
- A computerized tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) of his head and neck were negative.

Review of the hospital's document titled, "Current Summary Multiple Issues Feedback (345824)," dated 11/18/24, showed:
- Patient #4's daughter filed a grievance with the hospital due a fall which occurred on 10/10/24.
- The patient's daughter inquired if the hospital investigated Patient #4's fall and if the sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety) not being present in the room contributed to the fall.
- The hospital informed the patient's daughter that an exact cause of the fall was not able to be determined but the staff involved with the incident were held accountable.

Review of the hospital's document titled, "Current Summary Fall Event (1104754)," dated 10/10/24, showed:
- At 1:00 AM, Patient #4's bed alarm went off. The patient's RN entered the room and found the patient on the floor.
- He was alert, awake, and oriented times two (A&O x 2, refers to being alert and oriented to person and place), with no signs of injury. The patient's one-to-one (1:1, continuous visual contact with close physical proximity) reported that a patient care technician (PCT) informed her she would be taking over sitting with the patient. The 1:1 sitter gathered her belongings and left.
- When the patient fell, a staff member was not present in the room observing the patient.

Review of Patient #4's medical record dated 10/02/25, showed:
- He was a 63-year-old who presented to the hospital with blood drainage from his urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage). A 1:1 sitter was placed to observe the patient.
- Nursing documented a fall risk assessment which showed he was a high fall risk, on admission.
- Fall risk interventions which were initiated for the patient included, a yellow fall risk bracelet, yellow fall risk socks, his bed was in a low position, three of four bedrails were up and his bed alarm was on. He also had a 1:1 sitter placed in his room for safety.
- On 10/10/24 at 1:00 AM, he suffered an unwitnessed fall. The patient's bed alarm went off and when his RN responded, he was on the floor. Nursing documented the patient was A & O x 2, without any signs of injury.

Review of Patient #5's medical record dated 09/23/24, showed:
- She was an 84-year-old who presented in the ED for gastrointestinal hemorrhage (excessive bleeding that starts in the intestinal tract).
- On 09/23/24 at 5:07 PM, nursing documented fall risk assessment which showed she was not at risk for falls. Her bed rails were up, the bed was low and her call light was close by. There were no fall precautions ordered.
- On 09/24/24 at 12:30 AM, ED notes showed Patient #5 fell while trying to get out of bed to use the bathroom. However, it was documented she was on the bedpan.
- At 12:45 AM, her fall risk assessment showed she was at high risk for falls. Additional fall interventions included, a yellow arm band, gripper socks and a bed alarm. A nursing assessment documented showed she was confused at her baseline.
- At 6:15 AM, a CT showed, bones in her left eye socket were broken, with possible other eye structure involvement.

During an interview on 07/29/25 at 10:00 AM, Staff EE, Safety Sitter, stated that she was not Patient #4's 1:1 sitter but she was always expected to remain with the patient. Whenever she needed a break, she was expected to let a staff member on the unit know so someone could come relieve her. She would never leave the patient alone without another staff member present.

During an interview on 07/30/25 at 8:50 AM, Staff L, Nurse Manager, stated that when a patient was identified as a high fall risk and had a 1:1 sitter, the bed alarm was still expected to be on at all times.

During an interview on 07/30/25 at 1:33 PM, Staff LL, Chief Nursing Officer (CNO) and Staff PP, Assistant CNO, stated that she expected bed alarms to be on at all times when a high risk fall patient was not actively receiving care, even when a sitter was in place. They expected the 1:1 sitter to remain in place at all times. Families and providers were to be notified of a patient's fall regardless of the time of day. Communication with the families and providers was to be documented in the medical record.

Review of the hospital's undated policy titled, "Suicide Prevention: Core Christian Hospital/Northwest Healthcare," showed patients have a right to be safe in the hospital. Patients who have had suicidal ideation (SI, thoughts of causing one's own death) or with suicidal behaviors need additional individualized precautions implemented to keep them safe from their own actions. Dangerous items include but were not limited to ligature (anything which could be used for the purpose of hanging or strangulation) points within the patient's environment that could be used for binding, looping or tying something else to in order to create a sustainable point of attachment that may result in self-harm or loss of life, such as hospital bed side rails and intravenous (IV, in the vein) poles.

Observation with concurrent interview on 07/28/25 at 3:15 PM, in the ED of the Northeast building, showed four psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) with stretchers with multiple ligatures risks including side rails and IV poles. Staff I, ED Director, stated that the lack of psychiatric safe beds was on his "radar and was a high priority." He was waiting on a capital budget request approval for the purchase of psychiatric safe beds.

Observation with concurrent interview on 07/29/25 at 8:44 AM, in the ED of the Northwest building, showed two psychiatric rooms with stretchers that had multiple ligature risks including side rails, IV poles and electric cords. Staff O, Manager, stated that she looked for stretchers without ligature risks when treating a patient with SI. They did not have psychiatric safe beds, so they relied on sitters for patient safety.

During an interview on 07/30/25 at 1:33 PM, with Staff LL, CNO and Staff PP, Assistant CNO, stated that she was not aware the ED did not have psychiatric safe beds. In the past the stretchers were removed from the room and a mattress was placed on the floor for high-risk suicide patients. She stated that she did not have a capital budget request for the purchase of psychiatric safe beds.

During an interview on 07/30/25 at 3:06 PM, Staff H, RN, stated that the stretchers were used for suicidal patients in the psychiatric safe rooms.

During an interview on 07/29/25 at 10:24 AM, Staff R, RN, stated that she had to find a psychiatric safe stretcher in the ED for a patient with SI. If she couldn't find one, she would ask a charge nurse to find one while she treated the patient.

Although requested the hospital did not provide a policy for telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring in the ED.

Observation with concurrent interview on 07/29/25 at 10:01 AM, in the ED of the Northwest building, showed telemetry monitors at the nurse's station had noncritical alarms sounding for several minutes without attention. Staff I, ED Director stated that the ED did not have centralized telemetry monitoring; the unit secretaries listened for alarms and notified the RNs.

During an interview on 07/29/25 at 10:01 AM, Staff P, ED Unit Secretary, stated that the telemetry monitor rang all the time, and she notified the RNs, but they did not expect her to check tones. Alarms were the RN's responsibility. She was not trained to know what the sounds meant. Concurrent observation showed an RN passed by and said they often "tune them out."

Observation with concurrent interview on 07/29/25 at 12:38 PM, in the ED of the Northeast building, showed the telemetry monitors had noncritical alarms sounding. The audible alarms were at a low decibel and difficult to hear in the busy environment. There was no dedicated observation of the telemetry monitors. Staff T, ED Manager, stated that there was no assigned monitor technician for the telemetry monitors. Eyes were not on the monitors 100% of the time. Staff listened for alarms and responded accordingly.

During an interview on 07/29/25 at 1:15 PM, Staff I, ED Director, stated that in his experience ED's did not have designated telemetry monitoring. The ED staff relied on audible tones. If the assigned nurse did not observe the alarm, other staff responded. Each patient room alarmed for the patient in that room, the room alarms did not sound for patients in other rooms. He expected every nurse to observe for visual dysrhythmia (abnormal heartbeat) and audible alarms. He expected all alarms were addressed and critical alarms were responded to. No drills were conducted for responding to the telemetry alarms. Staff were able to change the telemetry alarm parameters without a provider order. He believed the alarms were "loud enough" to be heard in the busy environment.

During an interview on 07/30/25 at 1:33 PM, Staff LL, CNO and Staff PP, Assistant CNO, stated that they liked that the telemetry monitors were visible in the ED nurses' stations, that allowed the charge nurse to see all the monitors. The alarms could be louder, but the ED was a loud place. The alarms in the patient rooms were loud enough. In their experience when an alarm sounded, staff reacted, and "usually" multiple people responded. Staff did not walk past a sounding alarm. There could be a better process with improved observation and monitoring. There was always something to learn.


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