HospitalInspections.org

Based on policy review, observation, staff interview, incident report review, video taped footage review, patient registration slip review, medical record review, switchboard operator call log review, grievance file review, complainant interview and job description review, the Governing Body failed to provide oversight and have systems in place to ensure the protection patients' rights, an organized nursing service and an effective quality assurance program to ensure the safety of patients.

Findings include:

A. The hospital failed to protect and promote patients' rights by failing to provide care in a safe setting and failing to ensure the resolution of grievances.

~cross refer to 482.13 Patients' Rights, Condition Tag A0115

B. The hospital failed to have an effective Nursing Service providing oversight of day to day operations to ensure adequately trained staff provided patient care and registered nursing staff supervised and evaluated patient care.

~cross refer to 482.23 Nursing Services, Condition Tag A0385

C. The hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients.

~cross refer to 482.21 Quality Assessment and Performance Improvement, Condition Tag A0263

Based on policy review, observation, staff interview, incident report review, video taped footage review, patient registration slip review, closed medical record review, switchboard operator call log review, grievance file review and complainant interview, the hospital failed to protect and promote patients' rights by failing to provide care in a safe setting and failing to ensure the resolution of grievances.

The findings include:

A. The hospital failed to provide care in a safe setting by failing to ensure a safe environment was maintained in the Emergency Department.

~Cross refer to 482.13(c)(2) Patient Rights Standard: Tag A0144

B. The hospital staff failed to provide written notice of the resolution of a grievance for 1 of 1 grievances reviewed (grievance for Patient #10).

~Cross refer to 482.13(a)(2)(iii) Patient Rights Standard Tag A0123

Based on policy review, grievance file review and complainant and staff interviews, the hospital staff failed to provide written notice of the resolution of a grievance for 1 of 1 grievances reviewed (grievance for Patient #10).

Findings include:

Hospital Policy entitled "PATIENT RIGHTS & RESPONSIBILITIES" revised March 2009 revealed, "Patient Complaint and Grievance Process: Any patient and /or family concerns regarding patient patient rights will be handled through the PACT process. If the patient/family wishes to file a formal grievance, the Patient Grievance Process will be followed....Grievance Process B. The Risk Manager or designee contacts the patient or their representative immediately upon notification to discuss the grievance....D. The Risk Manager notifies the appropriate department of the grievance. The department manager is responsible to conduct an investigation and resolve the matter. The investigation and resolution are put in writing by Management and returned to the Risk Manager. This investigation and resolution should not exceed 30 days unless there are extenuating circumstances....F. A written response, written in language the patient or their representative can understand, is prepared and sent to them by Risk Management within 7 days if possible, but not to exceed 30 days from the conclusion of the investigation. If the investigation will exceed 7 days, the patient will be notified in writing that the investigation is ongoing and a projected date for completion...."

Grievance file review on 3/03/2010 revealed Patient #10's spouse called hospital administration on 1/11/2010 (no time) and filed a grievance. Review revealed the spouse complained that Patient #10 had not been seen by a physician and did not receive discharge instructions when he was treated in the ED on 1/06/2010. Review revealed no documented evidence that a written resolution was sent to the complainant (51 days after the grievance was filed).

Telephone interview on 3/03/2010 at 1400 with Patient #10's spouse revealed she had registered a complaint/grievance with the hospital administrator on 1/11/2010 regarding the care Patient #10 received in the ED on 1/06/2010. Interview revealed she had not received a written resolution of the grievance from the hospital (51 days after the grievance was filed).

Interview with the Risk Manager on 3/04/2010 at 1430 revealed an investigation had been initiated regarding the grievance filed by Patient #10's spouse on 1/11/2010. Interview revealed the ED Medical Director was in the process of looking into the complaint. Interview revealed ED Medical Director had not notified the Risk Manager whether or not his investigation was complete. Interview confirmed that as of 3/04/2010 a written resolution had not been sent to the patient's spouse.

Based on policy review, observation, staff interview, incident report review, video taped footage review, patient registration slip review, closed medical record review and switchboard operator call log review, the hospital failed to provide care in a safe setting by failing to ensure a safe environment was maintained in the Emergency Department.

The findings include:

Review of current policy entitled "Mr Strong Alert Policy" with an effective date of July 2008 and a revised date of February 5, 2009 revealed, "GENERAL STATEMENT: To provide immediate de-escalation expertise and crisis prevention intervention techniques to the patient who is displaying escalating behaviors. The goal is to provide early and rapid intervention designed to prevent further escalation of symptoms and/or to assist with transfer of the patient to an appropriate level of care. This occurs all in the best interest of the patient and is focused on patient safety, patient needs, and values....POLICY: A. A Mr. Strong Team will be assigned and available to assist and manage persons in either inpatient or outpatient settings throughout the hospital whose behavioral health condition demonstrates an acute change and/or is worsening. B. The Mr. Strong Team representatives should respond to the situation immediately upon activation of an overhead page announcement of 'Mr. Strong' and location. C. 'Mr. Strong is intended as a therapeutic intervention to prevent the deterioration of a person in crisis and also to respond and deal with a patient whose condition has deteriorated to potential imminent danger to self or others. D. Criteria for inclusion in a Mr. Strong Team. 1. Crisis Prevention Intervention (CPI) Trained....C. Mr. Strong Team responsibilities: 1. The first Security Officer on the scene will be team leader. The Behavioral Health RN will evaluate the situation. All team members present will take direction from the team leader....D. Assessment and Protocol Initiation 1. The Mental Health Nurse shall further assess the patient, analyze the assessment data and implement appropriate Crisis Prevention Intervention (CPI) techniques and interventions....i. Immediately separate family, friends or others if they are creating the confrontation if possible. ii. Secure the room or remove medical equipment or furnishings that can be used as weapons. iii. Communicate behavioral expectations to the patient as well as potential consequences if the patient does not comply. iv. If behavior continues, the Mr. Strong Team leader will determine the need for restraint and or therapeutic hold...."

Observation on 03/03/2010 at 1100 of the Emergency Department (ED) lobby area revealed the lobby consisted of two separate waiting rooms, with a desk between the two that was staffed with a ED Liaison, a non-licensed staff member. Observation revealed both waiting rooms were visible from the reception desk. Observation revealed a glass-enclosed Security Office located in the waiting room to the right of the desk. Interview with the ED Liaison at the desk in the ED lobby during the observation (Liaison #3) revealed patients check in at the desk and then sit in either waiting room while they wait for triage and treatment. Interview revealed when a patient arrives at the ED he fills out a registration slip. Interview revealed the Liaison reviews the slip and notifies the triage nurse of the patient's chief complaint. Interview revealed the Liaison stays at the desk and should notify the nurse immediately if a patient needs help.

Review of a "Security Incident Report" dated 2/18/2010 at 1330 revealed Patient #9 was in the ED waiting room at 1242 and made the statement "I wonder what would happen if I slap a white lady". Review revealed Patient #9 "walked behind (Patient #8) and hit her behind the head."

Review of a Hospital Security Department report entitled "ED Incident" dated 2/18/2010 revealed, "1243 received Stat call to the ED. 1245 Arrived in ED lobby...While walking over to interview the perpetrator ...called 911 to request assistance."

Review of ED waiting room video taped footage dated 02/18/2010 revealed Patient #9 (a male patient) entered the ED at 1222 with his mother. Review revealed the patient's mother signed him in at the ED reception desk. Review revealed no staff were present at the reception desk. Review revealed Patient #9 and his mother then took a seat in the left side waiting room.

Review of the registration slip completed by Patient #9's mother on 02/18/2010 at 1222 when the patient arrived at the ED revealed the reason the patient was seeking treatment was for a physical.

Further review of ED waiting room video taped footage dated 02/18/2010 revealed at 1225 the ED Liaison went to the desk, took the registration slip that Patient #9's mother had signed in on off of the clip board and looked at it. Review revealed at 1227 Patient #9 walked to the right side waiting room, paced for a bit then sat in a chair. Review revealed at 1227 Patient #9's mother went to the desk, talked to the ED Liaison and then returned to the waiting room. Further review revealed at 1230 Patient #8 entered the ED in a wheelchair with her husband's assistance. Review revealed Patient #8 signed in at the reception desk and then sat in her wheelchair in the lobby accompanied by her husband. Review revealed Patient #9 returned to the left side waiting room at 1242, where Patient #8 sat in a wheelchair with her husband at her side. Review revealed at 1243 Patient #9 walked up behind Patient #8 and hit her on the back of her head as she sat in a wheelchair in the lobby. Review revealed another patient that was waiting for treatment pushed Patient #8 in her wheelchair to the other lobby area where she continued to wait with her husband. Video review revealed at 1245 (3) Security and (1) Maintenance staff members arrived in the ED lobby, briefly spoke with Patient #9's mother in the left side lobby and then went to the right side lobby and stayed with Patient #8. Review revealed Patient #9 stayed in the left side lobby area with his mother and (2) other patients that were awaiting treatment in the ED. Review revealed no hospital staff were in the left side waiting room where Patient #9 sat with other patients. Review revealed at 1248 Patient #9 stood up, ran to the right side lobby area, hit a Security staff member, hit Patient #8's husband, knocking him to the floor, and then hit the Maintenance staff member. Video taped footage review revealed the City Police Officers arrived to the ED at 1249, at which time they subdued and handcuffed Patient #9. Review revealed the ED charge nurse entered the waiting room at 1249, after the police were present.

Closed record review for Patient #6 revealed a 64 year-old male that was attacked by Patient #9 in the ED waiting room on 02/18/2010 at 1248 (Patient #8's husband). Record review revealed Patient #6 sustained a fractured ankle during the attack and required surgical intervention. Record review revealed the patient was discharged to home on 02/22/2010 (4 days after being attacked by Patient #9 in the ED).

Review of hospital switchboard operator call log dated 02/18/2010 revealed at 1248 an ED staff member called a Code Mr. Strong and the operator announced it overhead (5 minutes after Patient #9 hit Patient #8 in the ED waiting room).

Interview with ED Liaison #2 on 3/3/2010 at 1015 revealed the Liaison worked as a nursing assistant in the ED on 02/18/2010 during the day shift. Interview revealed the nursing assistant also worked as an ED Liaison at the reception desk and had in fact relieved ED Liaison #1 for break on 02/18/2010 and was responsible for the check-in area at 1222 when Patient #9 arrived at the ED. Interview revealed the Liaison reviewed the patient's registration slip and did not ask the patient or his mother to clarify the reason the patient sought treatment. Further interview revealed ED Liaison #2 had not been trained regarding Code Mr. Strong and she did not know what it meant.

Telephone interview with ED Liaison #1 on 3/3/2010 at 1405 revealed the Liaison was at the reception desk when Patient #9 hit Patient #8. Interview revealed the Liaison called the operator and asked her to page Security to go to the ED for assistance. Interview revealed the Liaison did not call a Code Mr. Strong or notify the charge nurse. Interview revealed the Liaison did not know what "Code Mr. Strong" meant. Interview revealed, "If I have been informed of this policy I may have forgotten." Further interview revealed the Liaison had received no education to the Code Mr. Strong policy since Patient #9 assaulted Patient #8, staff members and Patient #8's husband in the ED waiting room on 02/18/2010.

Interview with the ED charge nurse on 3/3/2010 at 1040 revealed the ED Liaison staff at the front check in desk should have called a Code Mr. Strong immediately after Patient #9 hit Patient #8 on 02/18/2010 at 1243. Further interview revealed the ED Liaison should have called the charge nurse immediately after Patient #9 hit Patient #8 on 02/18/2010 at 1243 to alert her to the situation. Interview revealed the ED Liaison did not notify the charge nurse of the assault. Interview revealed if the Liaison had notified her of the first assault that she would have called a Code Mr. Strong to get more help to respond to the emergency and to help get the situation under control. Interview revealed the charge nurse became aware of the situation when an endoscopy technician told her there was a fight in the lobby. Interview revealed the police were present when the charge nurse arrived in the lobby.

Interview with the Security supervisor on 3/3/2010 at 1335 revealed the Security Office in the ED waiting room was usually, but not always, staffed with a Security Officer. Interview revealed anytime a patient's behavior is "combative or out of control" staff must initiate a Mr. Strong Alert by calling the hospital operator. Interview revealed the operator then announced the Mr. Strong Alert overhead three times and the Mr. Strong Alert team responded immediately. Interview revealed members of the Mr. Strong Alert team consisted of several staff members that were specially trained in de-escalation techniques, including nurses and security staff. Interview revealed a physician usually responded to a Mr. Strong Alert also. Interview revealed when Patient #9 hit Patient #8 in the ED lobby on 02/18/2010 at 1243 a Mr. Strong Alert should have been called. Interview revealed the ED Liaison staff called the operator requested for Security to go the ED stat after Patient #9 hit Patient #8. Interview revealed the ED Liaison did not call a Mr. Strong Alert as required by hospital policy. Interview revealed if the ED Liaison would have called a Mr. Strong Alert instead of paged for Security to go to the ED, more staff would have immediately responded. Interview revealed, "Several people from the ED and from across the hospital would have come. We definitely would have gotten more people (to respond with a Code Mr. Strong)....We needed more help than we had available, so we called 911 immediately."

Based on policy review, video taped footage review, staff interview and medical record review, the hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients.

The findings include:

1. The hospital failed to have a system or process in place to evaluate and analyze the hospital's response to behavioral health emergencies.

~cross refer to 482.21(a)(2) QAPI Standard: Tag A0267

2. The hospital failed to implement actions to prevent patient falls and improve post-fall nursing assessments.

~cross refer to 482.21(c)(2) QAPI Standard: Tag A0288

Based on policy review, video taped footage review and staff interview, the hospital failed to have a system or process in place to evaluate and analyze the hospital's response to behavioral health emergencies.

Findings include:

Review of current policy entitled "Mr Strong Alert Policy" with an effective date of July 2008 and a revised date of February 5, 2009 revealed, "GENERAL STATEMENT: To provide immediate de-escalation expertise and crisis prevention intervention techniques to the patient who is displaying escalating behaviors. The goal is to provide early and rapid intervention designed to prevent further escalation of symptoms and/or to assist with transfer of the patient to an appropriate level of care. This occurs all in the best interest of the patient and is focused on patient safety, patient needs, and values....POLICY: A. A Mr. Strong Team will be assigned and available to assist and manage persons in either inpatient or outpatient settings throughout the hospital whose behavioral health condition demonstrates an acute change and/or is worsening. B. The Mr. Strong Team representatives should respond to the situation immediately upon activation of an overhead page announcement of 'Mr. Strong' and location. C. 'Mr. Strong is intended as a therapeutic intervention to prevent the deterioration of a person in crisis and also to respond and deal with a patient whose condition has deteriorated to potential imminent danger to self or others...."

Review of ED waiting room video taped footage dated 02/18/2010 revealed Patient #9 (a male patient) entered the ED at 1222 with his mother. Review revealed the patient's mother signed him in at the ED reception desk. Review revealed no staff were present at the reception desk. Review revealed Patient #9 and his mother then took a seat in the left side waiting room. Review revealed at 1225 the ED Liaison went to the desk, took the registration slip that Patient #9's mother had signed in on off of the clip board and looked at it. Review revealed at 1227 Patient #9 walked to the right side waiting room, paced for a bit then sat in a chair. Review revealed at 1227 Patient #9's mother went to the desk, talked to the ED Liaison and then returned to the waiting room. Further review revealed at 1230 Patient #8 entered the ED in a wheelchair with her husband's assistance. Review revealed Patient #8 signed in at the reception desk and then sat in her wheelchair in the lobby accompanied by her husband. Review revealed Patient #9 returned to the left side waiting room at 1242, where Patient #8 sat in a wheelchair with her husband at her side. Review revealed at 1243 Patient #9 walked up behind Patient #8 and hit her on the back of her head as she sat in a wheelchair in the lobby. Review revealed another patient that was waiting for treatment pushed Patient #8 in her wheelchair to the other lobby area where she continued to wait with her husband. Video review revealed at 1245 (3) Security and (1) Maintenance staff members arrived in the ED lobby, briefly spoke with Patient #9's mother in the left side lobby and then went to the right side lobby and stayed with Patient #8. Review revealed Patient #9 stayed in the left side lobby area with his mother and (2) other patients that were awaiting treatment in the ED. Review revealed at 1248 Patient #9 stood up, ran to the right side lobby area, hit a Security staff member, hit Patient #8's husband, knocking him to the floor, and then hit the Maintenance staff member.

Interview with the Security supervisor on 3/3/2010 at 1335 revealed anytime a patient's behavior is "combative or out of control" staff must initiate a Mr. Strong Alert by calling the hospital operator. Interview revealed the operator then announced the Mr. Strong Alert overhead three times and the Mr. Strong Alert team responded immediately. Interview revealed members of the Mr. Strong Alert team consisted of several staff members that were specially trained in de-escalation techniques, including nurses and security staff. Interview revealed a physician usually responded to a Mr. Strong Alert also. Interview revealed when Patient #9 hit Patient #8 in the ED lobby on 02/18/2010 at 1243 a Mr. Strong Alert should have been called. Interview revealed the ED Liaison staff called the operator requested for Security to go the ED stat after Patient #9 hit Patient #8. Interview revealed the ED Liaison did not call a Mr. Strong Alert as required by hospital policy. Interview revealed if the ED Liaison would have called a Mr. Strong Alert instead of paged for Security to go to the ED, more staff would have immediately responded. Interview revealed, "Several people from the ED and from across the hospital would have come. We definitely would have gotten more people (to respond with a Code Mr. Strong)....We needed more help than we had available, so we called 911 immediately."

Interview with the Director of Quality Care Coordination on 3/4/2010 at 1500 revealed staff response to behavioral emergencies at the hospital, including Code Mr. Strong Alerts, had not been monitored and evaluated. Interview revealed, "We've not quantified that in a report, that I'm aware of."

Based on medical record review and staff interview the hospital failed to implement actions to prevent patient falls and improve post-fall nursing assessments.

The findings include:

Closed medical record review for Patient #3 revealed a 45 year-old female that was admitted to the 2W unit on 02/02/2010 with Dilantin toxicity (high/toxic blood levels of Dilantin - an anticonvulsant medication) and hepatic encephalopathy (impaired mental functioning secondary to advanced liver disease). Record review revealed the patient was treated and subsequently discharged on 02/16/2010. Record review revealed the patient had a history of an unsteady gait and falls for several months prior to admission. Record review revealed upon admission the patient was intermittently disoriented with slurred speech, impaired coordination and an unsteady gait. Review of physician's admission orders dated 02/02/2010 at 1830 revealed, "...Activity: Fall precaution...." Review of the admission nursing assessment dated 02/02/2010 at 2020 revealed, "...Gait...impaired....Mental Status...Forgets Limitations....Morse Fall Risk Total...70 (at risk for falls)...." Record review revealed falls precautions that were implemented upon admission included reorientation, bed in low position with bed alarm on, call light and telephone in reach, adequate lighting, non-cluttered environment, non-skid footwear, toileting every 2 hours, yellow bracelet on the patient and a yellow dot on the door (to alert staff to the high risk for falls). Review of nurse's notes dated 02/03/2010 at 0830 revealed the patient was confused with generalized weakness and an impaired gait. Record review revealed on 02/03/2010 at 0900 the patient was found on the floor in her room. Review of nurse's notes dated 02/03/2010 at 0900 revealed, "Post Falls Assessment....Type of Fall...Unobserved...Found on Floor....Is the Patient on Anticoagulant Therapy?...N (No)....Family Notified...N Report given when family arrived....Physician notified...Y (Yes)....Bed Alarm...N WAS FOUND TO NOT BE ON....FOUND PT (Patient) ON FLOOR AT OPPOSITE SIDE OF THE ROOM UNABLE TO GET UP BY SELF NO SIGNS OF INJURIES RETURNED TO BED....BED ALARMS TURNED ON." Further record review revealed the patient sustained another unobserved fall on 02/06/2010 at 0600. Review of a physician's telephone order dated 02/06/2010 at 0615 revealed, "...Neuro checks q (every) 1 (hour) x (for) 12 (hours)." Record review revealed no documentation that nursing staff performed hourly neuro checks on 02/06/2010 between 0630 and 0800 (1 hour and 30 minutes), 1200 and 1345 (1 hour and 45 minutes), 1345 and 1450 (1 hour and 5 minutes) and 1450 and 1615 (1 hour and 25 minutes).

Interview on 03/04/2010 at 0900 with the Nurse Manager of 2W, the unit on which Patient #3 was hospitalized in February 2010, revealed after the patient fell on 02/03/2010 the nurse reported to the Manager that she thought the alarm had been on, but it didn't work. Interview revealed the Manager told the nurse that engineering had told her in the past that if the bed was not zeroed out before a patient was put in the bed (to calibrate it to the patient's weight) the alarm may not work. Interview revealed, "The bed alarm was on it just didn't work because the bed had not been zeroed out." Interview revealed the Manager did not educate the rest of the nursing staff on the unit about the problem engineering had identified with the bed alarms. Further interview revealed the Manager was a member of the hospital wide Falls Team. Interview revealed, "We review the number of falls and the reasons for falls....If we identify a trend, we educate staff to that trend." Interview revealed the problem with bed alarms not functioning due to beds not being zeroed has not been discussed in any of the monthly Falls Team meetings. Further interview revealed the Manager was aware nursing staff did not perform neuro checks on Patient #3 every hour for 12 hours as ordered by the physician. Interview revealed, "I did see where there was a little time lag between the every one hour neuro checks." Interview revealed the Manager had not re-educated the nursing staff on the unit to follow physician's orders for neuro checks after a fall. Interview revealed, "I haven't got a plan in place for this one."

Interview on 03/04/2010 at 1530 with the Director of Quality Care Coordination revealed, "We have a Falls Team that gets the data on falls....I look at all falls." Interview revealed the Director analyzed falls data and evaluated the data for trends. Interview revealed the Director was not aware of any problems with bed alarms not functioning due to beds not being zeroed. Interview revealed, "We have no problems with bed alarms that I'm aware of."

Based on policy review, job description review, observation, staff interview, video taped footage review, patient registration slip review, switchboard operator call log review and medical record review, the hospital failed to have an effective Nursing Service providing oversight of day to day operations to ensure adequately trained staff provided patient care and registered nursing staff supervised and evaluated patient care.

The findings include:

A. The hospital failed to ensure 2 of 2 ED Liaison staff were trained and competent to respond to a behavior health emergency in the ED lobby.

~Cross refer to 482.23(b) Nursing Services Standard: Tag A0392

B. The hospital's nursing staff failed to supervise and evaluate patient care by failing to implement measures to prevent a recurrent fall and failing to assess and treat an injury after a fall for 1 of 5 sampled patients that had falls (Patient #3).

~Cross refer to 482.23(b)(3) Nursing Services Standard: Tag A0395

Based on policy review, job description review, observation, staff interview, video taped footage review, patient registration slip review and switchboard operator call log, the hospital failed to ensure 2 of 2 ED Liaison staff were trained and competent to respond to a behavior health emergency in the ED lobby.

Findings include:

Review of current policy entitled "Mr Strong Alert Policy" with an effective date of July 2008 and a revised date of February 5, 2009 revealed, "GENERAL STATEMENT: To provide immediate de-escalation expertise and crisis prevention intervention techniques to the patient who is displaying escalating behaviors. The goal is to provide early and rapid intervention designed to prevent further escalation of symptoms and/or to assist with transfer of the patient to an appropriate level of care. This occurs all in the best interest of the patient and is focused on patient safety, patient needs, and values....POLICY: A. A Mr. Strong Team will be assigned and available to assist and manage persons in either inpatient or outpatient settings throughout the hospital whose behavioral health condition demonstrates an acute change and/or is worsening. B. The Mr. Strong Team representatives should respond to the situation immediately upon activation of an overhead page announcement of 'Mr. Strong' and location. C. 'Mr. Strong is intended as a therapeutic intervention to prevent the deterioration of a person in crisis and also to respond and deal with a patient whose condition has deteriorated to potential imminent danger to self or others...."

Review of the job description for the "Emergency Department Lobby Technician (Liaison) revealed, "Provides for the basic personal needs of patients to the extent warranted by condition/capabilities of patient....-Accurately relays information between patients, patient families, nursing ancillary departments and physicians within appropriate time frames.
-Ensures that any unusual or adverse symptoms or behaviors are immediately reported to appropriate nurse....8. Communicates and collaborates with physicians and other members of the health care team. -Provides clear, relevant and accurate communications with respect to patient status, progress and concerns...-Ensures that professional care provider is immediately notified when unusual or adverse signs are observed. - Observes patients for unusual or adverse signs and reports to professional staff...."

Observation on 03/03/2010 at 1100 of the Emergency Department (ED) lobby area revealed the lobby consisted of two separate waiting rooms, with a desk between the two that was staffed with a ED Liaison, a non-licensed staff member. Observation revealed both waiting rooms were visible from the reception desk. Observation revealed a glass-enclosed Security Office located in the waiting room to the right of the desk. Interview with the ED Liaison at the desk in the ED lobby during the observation (Liaison #3) revealed patients check in at the desk and then sit in either waiting room while they wait for triage and treatment. Interview revealed when a patient arrives at the ED he fills out a registration slip. Interview revealed the Liaison reviews the slip and notifies the triage nurse of the patient's chief complaint. Interview revealed the Liaison stays at the desk and should notify the nurse immediately if a patient needs help.

Review of ED waiting room video taped footage dated 02/18/2010 revealed Patient #9 (a male patient) entered the ED at 1222 with his mother. Review revealed the patient's mother signed him in at the ED reception desk. Review revealed no staff were present at the reception desk. Review revealed Patient #9 and his mother then took a seat in the left side waiting room.

Review of the registration slip completed by Patient #9's mother on 02/18/2010 at 1222 when the patient arrived at the ED revealed the reason the patient was seeking treatment was for a physical.

Further review of ED waiting room video taped footage dated 02/18/2010 revealed at 1225 the ED Liaison went to the desk, took the registration slip that Patient #9's mother had signed in on off of the clip board and looked at it. Review revealed at 1227 Patient #9 walked to the right side waiting room, paced for a bit then sat in a chair. Review revealed at 1227 Patient #9's mother went to the desk, talked to the ED Liaison and then returned to the waiting room. Further review revealed at 1230 Patient #8 entered the ED in a wheelchair with her husband's assistance. Review revealed Patient #8 signed in at the reception desk and then sat in her wheelchair in the lobby accompanied by her husband. Review revealed Patient #9 returned to the left side waiting room at 1242, where Patient #8 sat in a wheelchair with her husband at her side. Review revealed at 1243 Patient #9 walked up behind Patient #8 and hit her on the back of her head as she sat in a wheelchair in the lobby. Review revealed another patient that was waiting for treatment pushed Patient #8 in her wheelchair to the other lobby area where she continued to wait with her husband. Video review revealed at 1245 (3) Security and (1) Maintenance staff members arrived in the ED lobby, briefly spoke with Patient #9's mother in the left side lobby and then went to the right side lobby and stayed with Patient #8. Review revealed Patient #9 stayed in the left side lobby area with his mother and (2) other patients that were awaiting treatment in the ED. Review revealed no hospital staff were in the left side waiting room where Patient #9 sat with other patients. Review revealed at 1248 Patient #9 stood up, ran to the right side lobby area, hit a Security staff member, hit Patient #8's husband, knocking him to the floor, and then hit the Maintenance staff member. Video taped footage review revealed the City Police Officers arrived to the ED at 1249, at which time they subdued and handcuffed Patient #9. Review revealed the ED charge nurse entered the waiting room at 1249, after the police were present.

Review of hospital switchboard operator call log dated 02/18/2010 revealed at 1248 an ED staff member called a Code Mr. Strong and the operator announced it overhead (5 minutes after Patient #9 hit Patient #8 in the ED waiting room).

Interview with the Security supervisor on 3/3/2010 at 1335 revealed anytime a patient's behavior is "combative or out of control" staff must initiate a Mr. Strong Alert by calling the hospital operator. Interview revealed the operator then announces the Mr. Strong Alert overhead three times and the Mr. Strong Alert team responded immediately. Interview revealed members of the Mr. Strong Alert team consisted of several staff members that were specially trained in de-escalation techniques, including nurses and security staff. Interview revealed a physician usually responded to a Mr. Strong Alert also. Interview revealed when Patient #9 hit Patient #8 in the ED lobby on 02/18/2010 at 1243 a Mr. Strong Alert should have been called. Interview revealed the ED Liaison staff called the operator requested for Security to go the the ED stat after Patient #9 hit Patient #8. Interview revealed the ED Liaison did not call a Mr. Strong Alert as required by hospital policy. Interview revealed if the ED Liaison would have called a Mr. Strong Alert instead of paged for Security to go to the ED, more staff would have immediately responded. Interview revealed, "Several people from the ED and from across the hospital would have come. We definitely would have gotten more people (to respond with a Code Mr. Strong)....We needed more help than we had available, so we called 911 immediately." Interview confirmed the ED Liaison did not call a Mr. Strong Alert as required by hospital policy after Patient #9's first assault in the ED.

Interview with the ED charge nurse on 3/3/2010 at 1040 revealed the ED Liaison staff at the front check in desk should have called a Code Mr. Strong immediately after Patient #9 hit Patient #8 on 02/18/2010 at 1243. Further interview revealed the ED Liaison should have called the charge nurse immediately after Patient #9 hit Patient #8 on 02/18/2010 at 1243 to alert her to the situation. Interview revealed the ED Liaison did not notify the charge nurse of the assault. Interview revealed if the Liaison had notified her of the first assault that she would have called a Code Mr. Strong to get more help to respond to the emergency and to help get the situation under control. Interview revealed the charge nurse became aware of the situation when an endoscopy technician told her there was a fight in the lobby. Interview revealed the police were present when the charge nurse arrived in the lobby.

Interview with ED Liaison #2 on 3/3/2010 at 1015 revealed the Liaison worked as a nursing assistant in the ED on 02/18/2010 during the day shift. Interview revealed the nursing assistant also worked as an ED Liaison at the reception desk and had in fact relieved ED Liaison #1 for break on 02/18/2010 and was responsible for the check-in area at 1222 when Patient #9 arrived at the ED. Interview revealed the Liaison reviewed the patient's registration slip and did not ask the patient or his mother to clarify the reason the patient sought treatment. Further interview revealed ED Liaison #2 had not been trained regarding Code Mr. Strong and she did not know what it meant.

Telephone interview with ED Liaison #1 on 3/3/2010 at 1405 revealed the Liaison was at the reception desk when Patient #9 hit Patient #8. Interview revealed the Liaison called the operator and asked her to page Security to go to the ED for assistance. Interview revealed the Liaison did not call a Code Mr. Strong or notify the charge nurse. Interview revealed the Liaison did not know what "Code Mr. Strong" meant. Interview revealed, "If I have been informed of this policy I may have forgotten." Further interview revealed the Liaison had received no education to the Code Mr. Strong policy since Patient #9 assaulted Patient #8, staff members and Patient #8's husband in the ED waiting room on 02/18/2010.

Based on policy review, medical record review and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to implement measures to prevent a recurrent fall and failing to assess and treat an injury after a fall for 1 of 5 sampled patients that had falls (Patient #3).

The findings include:

Review of current hospital policy entitled "Fall Prevention Policy" dated 01/27/2010 revealed, "PROCEDURES AND RESPONSIBILITIES: A. Initial Assessment/Screening:...Inpatient departments upon admission, the nurse will complete the Morse Fall Scale Risk Screening Tool and document this assessment and score....For a score of 45 and above, the nurse will implement the interventions. Interventions will be planned, implemented and documented according to each patient's risk level and individual needs....C. Fall Prevention Intervention: All patients with an at risk for falls score of 45 and above will have the following measures initiated as appropriate to individualized needs. a. At risk patients will have a yellow wristband applied, a yellow sticker on the outside of the chart and a yellow dot on the door....b. The patient's at risk status will be reported during change of shift report....c. The patient and family will be educated. Educational interventions may include but are not limited to: 1. Enlist family participation to support interventions and to alert the staff to any changes in the patient....2. Consider the use of sitters (family, church members) to engage the patient and remind the patient to ask for assistance if needed....d. Plan of Care Strategies: 1. General strategies for patients at risk for falls may include but are not limited to: Bed in low position; activate bed alarm....Restraints may be utilized for patient safety with physician order after other alternatives have been unsuccessful....2. Strategies for reduction of anticipated physiologic falls may include but are not limited to:...Frequent reassessment....D. Post Fall Management: Assess for any injury....Monitor patient as condition warrants...."

Closed medical record review for Patient #3 revealed a 45 year-old female that was admitted to the 2W unit on 02/02/2010 with Dilantin toxicity (high/toxic blood levels of Dilantin - an anticonvulsant medication) and hepatic encephalopathy (impaired mental functioning secondary to advanced liver disease). Record review revealed the patient was treated and subsequently discharged on 02/16/2010. Record review revealed the patient had a history of an unsteady gait and falls for several months prior to admission. Record review revealed upon admission the patient was intermittently disoriented with slurred speech, impaired coordination and an unsteady gait. Review of physician's admission orders dated 02/02/2010 at 1830 revealed, "...Activity: Fall precaution...." Review of the admission nursing assessment dated 02/02/2010 at 2020 revealed, "...Gait...impaired....Mental Status...Forgets Limitations....Morse Fall Risk Total...70 (at risk for falls)...." Record review revealed falls precautions that were implemented upon admission included reorientation, bed in low position with bed alarm on, call light and telephone in reach, adequate lighting, non-cluttered environment, non-skid footwear, toileting every 2 hours, yellow bracelet on the patient and a yellow dot on the door (to alert staff to the high risk for falls). Review of nurse's notes dated 02/03/2010 at 0830 revealed the patient was confused with generalized weakness and an impaired gait. Record review revealed on 02/03/2010 at 0900 the patient was found on the floor in her room. Review of nurse's notes dated 02/03/2010 at 0900 revealed, "Post Falls Assessment....Type of Fall...Unobserved...Found on Floor....Is the Patient on Anticoagulant Therapy?...N (No)....Family Notified...N Report given when family arrived....Physician notified...Y (Yes)...." Review of the Medication Administration Record (MAR) revealed the patient received Lovenox (anticoagulant) via subcutaneous injection on 02/03/2010 at 0007, and thus was on Anticoagulant Therapy at the time of the fall. Further review of nurse's notes dated 02/03/2010 at 0900 revealed, "Bed Alarm...N WAS FOUND TO NOT BE ON....FOUND PT (Patient) ON FLOOR AT OPPOSITE SIDE OF THE ROOM UNABLE TO GET UP BY SELF NO SIGNS OF INJURIES RETURNED TO BED....BED ALARMS TURNED ON." Record review revealed on 02/03/2010 at 0900 the nurse reassessed the patient for falls risk, found the Morse Fall Risk Total score to be 95 (at risk for falls) and continued to implement the following falls precautions: reorientation, bed in low position with bed alarm on, call light and telephone in reach, adequate lighting, non-cluttered environment, non-skid footwear, toileting every 2 hours, yellow bracelet on the patient and a yellow dot on the door (no new interventions).

Review of nurse's notes dated 02/05/2010 at 2300 revealed, "Mental Status...Confused...Lethargic...Drowsy....Neurologic Comment...RESTLESS. GETS OUT OF BED WITHOUT EXPLANATION...USUALLY WANTS TO GO TO THE BATHROOM. NOT COMMUNICATIVE OF HER WISHES OR NEEDS. VERY FLOPPY AND WEAK ON HER FEET. 2 PERSON ASSIST....HER HUSBAND...IS STAYING OVERNIGHT BECAUSE OF HER FALLS RISK STATUS....Generalized Weakness....Morse Fall Risk Total...85 (at risk for falls)....Morse Falls Risk Comment...HIGH FALLS RISK...Bed Alarm...Y...." Record review revealed on 02/06/2010 at 0630 the patient was found on the floor in her room. Review of nurse's notes dated 02/06/2010 at 0630 revealed, "Post Falls Assessment....Type of Fall...Unobserved...Found on Floor....Is the Patient on Anticoagulant Therapy?...N....Bed Alarm On...Yes....Right Eye Abrasion (Scraped Skin)....Family Notified...N....Physician notified...Y....Post Falls Assessment Comments...(Name of Physician) WANTS NEURO(LOGICAL) OBSERVATIONS TO BE DONE FOR 12 HOURS. RIGHT EYE IS SWOLLEN." Review of the MAR revealed the patient received Lovenox via subcutaneous injection 02/03/2010 at 2239, on 02/04/2010 at 2031 and on 02/05/2010 at 2116, and thus was on Anticoagulant Therapy at the time of the fall. Record review revealed a physician's order dated 02/06/2010 at 1010 to discontinue Lovenox. Record review revealed nursing staff continued to implement the following falls precautions: reorientation, bed in low position with bed alarm on, call light and telephone in reach, adequate lighting, non-cluttered environment, non-skid footwear, toileting every 2 hours, yellow bracelet on the patient and a yellow dot on the door (no new interventions). Review of nurse's notes dated 02/06/2010 at 0900 revealed, "Mental Status...Confused...Lethargic...Drowsy....Neurologic Comment...pt difficult to arouse; no family present....Right Eye Abrasion (Scraped Skin)....Gait...Weak... Morse Fall Risk Total 85 (at risk for falls)....Morse Fall Risk Comment...HIGH FALLS RISK....Family or Sitter Present...N....Summary Comments Activities of Daily Living...pt laying in bed; uncooperative and difficult to arouse..."

Review of a physician's telephone order dated 02/06/2010 at 0615 revealed, "Apply antibiotic ointment to graze on eyebrow and cover with gauze. Neuro checks q (every) 1 (hour) x (for) 12 (hours)." Record review revealed the nurse applied antibiotic ointment to the patient's right eye wound on 02/06/2010 at 1800 (11 hours and 45 minutes after ordered by the physician). Further record review revealed no documentation that nursing staff performed hourly neuro checks on 02/06/2010 between 0630 and 0800 (1 hour and 30 minutes), 1200 and 1345 (1 hour and 45 minutes), 1345 and 1450 (1 hour and 5 minutes) and 1450 and 1615 (1 hour and 25 minutes). Review of physician's progress notes dated 02/06/2010 at 0950 revealed, "Patient sustained a fall early this am (morning) and has swelling of the Right upper eye lid + laceration and bleeding. She admits to pain on that side....Has a laceration on the right upper eye lid abt (about) 4 cm (centimeters) with swelling of the right eye...." Record review revealed the first documentation that nursing staff assessed the patient's wound to be more than a "Right Eye Abrasion (Scraped Skin)" on 02/06/2010 at 2010 (10 hours and 20 minutes after the physician documented a 4 cm laceration), when the nurse documented "...large hematoma to right eye with laceration...."

Further review of physician's orders dated 02/06/2010 at 1020 revealed, "Apply ice packs to rt (right) eye." Record review revealed the first documentation that nursing staff applied ice to the patient's right eye wound on 02/06/2010 at 2010 (7 hours and 50 minutes after the physician ordered ice packs to the right eye), when the nurse documented "...band-aide is present with ice pack. eye is swollen closed...."

Record review revealed documentation dated 02/06/2010 at 0910 the patient's mother called to check on the patient, at which time the nurse informed her the patient "fell @ 0600 this am". Review of nurse's notes dated 02/06/2010 at 1140 revealed, "(Name of physician) notified of family's request for x-ray and evaluation of right eye for stitches....(Name of physician) in room to speak with pt and family at 1142." Review of physician's orders dated 02/06/2010 at 0950 revealed, "Brain CT (computed tomography scan) stat." Review of physician's progress notes dated 02/06/2010 at 1730 revealed, "...Brain CT report - Old Rt medial orbital wall fracture; right fronto-orbital subcutaneous hematoma...."

Telephone interview on 03/04/2010 at 1130 with the nurse that was assigned to Patient #3 during the day shift on 02/06/2010 revealed the nurse was usually assigned to the obstetrical/pediatric unit. Interview revealed the nurse was pulled to staff on 2W on 02/06/2010. Interview revealed the nurse had never taken a patient assignment on 2W prior to 02/06/2010 and she was was assigned to (6) patients during the day shift . Interview revealed, "In report they told me she (Patient #3) fell and cut her eye....She had quite a large laceration on her right eye. It was 3-4 centimeters long. It was seeping blood, not bleeding bad, but just sort of seeping most of the morning. It was covered with old blood and had started to scab....I cleaned up her eye as good as I could, but tried not to remove the scab." Interview revealed the wound continued to bleed "just a little bit off and on" and the nurse cleaned it with a wash cloth throughout the day. Interview revealed the nurse saw the physician's order to apply antibiotic ointment to the patient's right eye wound late in the morning. Interview revealed antibiotic ointment was available on the unit, but the charge nurse told her she had to get it from pharmacy. Interview revealed the secretary ordered the ointment from pharmacy. Interview revealed when the nurse went off duty at 1500 or 1530 antibiotic ointment and gauze dressing had not yet been applied to the wound. Interview revealed the nurse was not sure when the ointment arrived to the floor and was put on the patient's wound. Interview revealed the nurse did not recall if the patient had an ice pack to her eye or not. Further interview revealed there was no family present in the patient's room when she came on duty at 0700. Interview revealed the family arrived at about 0900. Interview revealed the family was upset that the patient had sustained another fall. Interview revealed the nurse asked the family if they wanted the patient to be restrained. Interview revealed the family declined restraints and decided to stay with the patient.

Interview on 03/04/2010 at 0900 with the Nurse Manager of 2W, the unit on which Patient #3 was hospitalized in February 2010, revealed the nurse assigned to the patient at the time of her first fall was a travel nurse. Interview revealed after the patient fell on 02/03/2010 (first fall) the nurse reported to the Manager that she thought the alarm had been on, but it didn't work. Interview revealed the Manager told the nurse that engineering had told her in the past that if the bed was not zeroed out before a patient was put in the bed (to calibrate it to the patient's weight) the alarm may not work. Interview revealed, "The bed alarm was on it just didn't work because the bed had not been zeroed out." Interview revealed no new falls prevention interventions were implemented after the first fall. Interview revealed the nurse that was assigned to the patient at the time of her second fall was a travel nurse and was no longer employed at the hospital. Interview revealed the Manager reviewed the fall and discussed it with the nurse the following day. Interview revealed the patient's significant other had stayed with the patient during the night of 02/05/2010, but left the hospital at about 0530 on 02/06/2010. Interview revealed the patient's significant other told the nurse that he was leaving and the patient was alone in her room. Interview revealed, "She (the nurse) told me she knew he left and the bed alarm was on. The (bed) alarm went off (at about 0600 on 02/06/2010) and (the patient's nurse) and a few others went in and found the patient at the foot of the bed on the floor." Interview revealed the staff assisted the patient back to bed, cleaned blood off of the floor and cleaned the patient's head with a wash cloth. Interview revealed the patient's family arrived at the hospital within a few hours of the patient's second fall and stayed with her continuously until she was discharged. Further interview revealed the administration of Lovenox was anticoagulant therapy. Interview revealed it was important to know whether or not a patient that fell had received anticoagulant therapy because of the "risk for bleeding in the head" if the patient hit her head during the fall. Interview confirmed Patient #3 was on anticoagulant therapy at the times of her falls on 02/03/2010 and 02/06/2010 and nursing staff erroneously reported the patient was not on anticoagulant therapy on both post falls assessments. Further interview confirmed there was no documentation available that the nurse applied antibiotic ointment to the patient's right eye wound and covered the wound with gauze before 02/06/2010 at 1800 (11 hours and 45 minutes after ordered by the physician). Interview confirmed there was no available documentation that the nurse applied ice to the right eye wound before 02/06/2010 at 2010 (7 hours and 50 minutes after ordered by the physician). Further interview confirmed there was no available documentation that nursing staff performed hourly neuro checks on 02/06/2010 between 0630 and 0800 (1 hour and 30 minutes), 1200 and 1345 (1 hour and 45 minutes), 1345 and 1450 (1 hour and 5 minutes) and 1450 and 1615 (1 hour and 25 minutes). Further interview revealed nursing staff must assess any injuries or wounds immediately after a fall. Interview confirmed the first available documentation that nursing staff noted the patient had a laceration (rather than abrasion/scrape) on her right eye lid was on 02/06/2010 at 2010 (14 hours and 10 minutes after the patient fell and sustained an injury to her right eye). Interview revealed, "I would expect to see a more in depth assessment of the wound after a fall."

Interview on 03/04/2010 at 1300 with the Vice President (VP) of Clinical Services revealed falls prevention requires close monitoring, sometimes even restraint of patients if ordered by the physician. Interview revealed, "Turning the bed alarm on does not prevent a patient from falling."


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