HospitalInspections.org

Based on interviews and record reviews, the facility failed to meet the Condition of Participation (CoP) for Patient Rights by failing to protect and promote each patient's rights as evidenced by the following:

A. The facility failed to include the patient or family in the formation or updating of care plans. See Tag 130

B. The facility failed to provide care in a safe setting for their self identified high risk fall population. See Tag 144

Based on interviews and record reviews the facility failed to meet the Condition of Participation (CoP) for Nursing Services by failing to comply with the requirements as evidenced by the following:

A. The facility failed to keep nursing plans of care current and designed to meet high risk needs of fall prevention. See tag 396.

Based on record review of 3 (#1, 2, and 8) of the 10 sampled patients chosen based on having had falls during their hospital stay and staff interviews, the facility failed to include the patient or family in the formation or updating of care plans. This failed practice can negatively affect patient outcomes, especially after adverse events such as falls or changes in status. Without input from the patient or family, goals of care cannot be fully determined and priorities are not known.

The findings are:

A. Record Review of facility's "Fall Prevention" Policy that has been effective since 08/2012

1. Post fall instructions clearly state: "If a fall occurs, a comprehensive evaluation of the fall must be documented. The patient medical record will include an assessment of the patient's status, nature of injury if any and type of fall; physician and family notification and any interventions or treatment related to fall."


B. Record Review of Patient #2's nursing assessment notes from 12/7/2020-12/16/2020:

1. On 12/7/2020 at 1:15 am patient had an unwitnessed fall with no family notification documented.

2. On 12/8/2020 at 9:45 pm patient had an unwitnessed fall with no family notification documented.


C. Interview with Staff member #2 (Registered Nurse) on 12/17/2020 at 12:42 pm, indicated that there was no definitive method to verify patient #2's care plan was updated after fall. Staff member #2 reinforced that a patient's fall risk needs that are to be discussed during IPOC (Individual Plan of Care)/Team Conference Weekly Updates to formulate goals of care to prevent injury. Staff member #2 stated that during Weekly Updates, family input is to be included.


D. Record Review of patient #2's "IPOC/Team Conference Weekly Update" from 12/09/2020

1 .No mention of fall precautions in goals of care, mobility, or safety. Patient had fallen on 12/08/2020.

2. No mentioning of family involvement during the IPOC meeting or in the reprioritization of goals of care.


E. Record Review of patient #2's "Nursing Care Plan" from 12/07/2020-12/08/2020

1. No evidence of care plan updated to reflect fall on 12/08/2020.


F. Record Review of Patient #2's "Action Cue Event Reports"(Action Cue" is the facility's internal software to report adverse or unexpected events.) from 12/7/2020 to 12/8/2020

1. Event entered on 12/7/2020 indicates that patient fell "Found sitting on floor." No documentation of family notification.

2. Event entered on 12/8/2020 indicates that patient fell "Walked by patient's room and found patient on floor" No documentation of family notified.



G. Record review of Patient #1's "Nursing Assessment Notes" dated from 4/20/2020 to 4/28/2020 revealed the following:

1. Nursing note states on 4/20/2020 at 7:09 pm "Patient (pt) found on floor by License Practical Nurse (LPN), pt states he hit his head no bumps and bruising." No documentation of provider or family notification.

2. Pt is taking Plavix (blood thinning medication) that has a higher risk of bleeding if a fall occurs

3. Neurovascular assessment (Neurovascular assessment is assessing the patient's level of consciousness, orientation, and other factors associated to neuro functioning) was done in nursing notes; however, it does not state if it was done prior to or after fall.

4. Nursing notes on 4/22/2020 at 6:05 pm "Patient found on ground confused with initial blood pressure 75/35(Very low Blood Pressure Normal is 130 to 140 / 70 to 80)." No documentation of family notification

5. Nursing note on 4/24/2020 at 7:10 pm "Patient found sitting on floor mat by bed with large bruise to left leg, unable to tell when this occurred." No documentation of bruising on leg from nursing assessment on 4/23/2020. No documentation of family notification.

6. Nursing note on 4/26/2020 at 6 am states "patient received from floor, VS WNL (vital signs within normal limits)" Wording from note does not clearly highlight a fall. No MD (Medical Doctor) or Family notification documented.


H. Record review of Patient #1's "IPOC/Team Conference Weekly Update" (IPOC- Individualized Plan of Care) from 4/21/2020 and 4/28/2020

1. No mention of fall precautions as a highlighted area of concern regarding safety or mobility even though the patient had multiple falls.

2. No mentioning of family involvement during the IPOC meeting or in the reprioritization of goals of care.


I. Record Review of Patient #1's "Action Cue Event Reports" ("Action Cue" is the facility's internal software to report adverse or unexpected events.) from 4/20/2020 to 4/26/2020

1. Facility's review of the Action Cue Report regarding fall event on 4/22/2020 states "Lack of documentation of family notification of event"

2. Facility's review of the Action Cue Report regarding fall event on 4/24/2020 states "Lack of documentation of family notification of event" and "lack of care plan update"

3. Facility's review of Action Cue Report regarding fall event on 4/26/2020 indicates that daughter was notified.

4. The facilities' Severity scale for falls from all 4 events as described from facility's own review is noted as "Level III- Serious: variances where the potential for litigation is thought to be prevalent. Major injury or impairment in which the patient's, visitor's, or employee's function is altered long-term or permanently."


J. Record Review of Patient #8's nursing assessment notes from 5/29/2020 to 6/3/2020:

1. On 5/29/2020 at 9:45 am nursing note states that patient had a medication error "Patient received 1 gram of Cefepime (antibiotic, medication) instead of 2 grams of Ceftriaxone (antibiotic, medication). No documentation of family notification or if reported as adverse event.

2. Nursing note on 6/3/2020 at 900 am "Patient found on the floor" no assessment, no Physician notification, or family notification documented.


K. Record Review of Patient #8's "Action Cue Event Reports" from 5/23/2020 to 6/3/2020:

1. Event entered on 5/23/2020 indicates that patient fell "Found sliding from the bed and she is in a squatting position, and she has a big bowel movement, and her restraints still on" No documentation of family or provider notified.

2. Event entered on 5/25/2020 indicates that patient fell "Patient was found lying on her back with restraints still tied to her bed". No documentation of family or provider notified.

3. Event entered on 6/3/2020 indicates that patient fell and the staff marked that the patient had hit their head (no investigation documented). This was overridden by facility's review manager (S#11 - Risk Manager) to indicate "No apparent injury" No documentation of family notification.


L. Interview with Staff member #11 (Registered Nurse and Director) on 12/17/2020 at 1:04 pm indicated that the "Action Cue" reporting software is for tracking and quality improvement only. Staff member #11 reinforced that "Action Cue" is not part of a patient's medical record and that documentation of a fall should not solely be done in it.

Based on observation and interview, the facility failed to provide personal privacy for 1 (P2) patient. This failed practice has the potential to cause harm to patient's emotional health, respect, dignity, and comfort.

The findings are:

A. On 12/16/20 at 10:30 am during observation, the following was observed:

S7 (Physical Therapist) and S8 (Physical Therapist Assistant) were observed assisting P2 (Patient) walking in a hallway within view of other patients, vendors, and staff. S7 and S8 were using the Drag Lift method (lifting or supporting a patient under the armpit), which caused P2's gown to come up from the back causing his buttocks and legs to be uncovered. V1 (Vendor employee) was standing a few feet from the entrance to the hallway waiting to proceed down the same hallway. S4 (License Practical Nurse) standing at the Nurse's station noticed P2's buttocks and legs uncovered and went and placed a gown over P2's back side.

B. 12/16/20 at 10:35 am during interview, S8 confirmed when assisting a patient to walk, tries to make sure patient's gown is not shortened to expose the buttocks and legs. S8 confirmed was not aware P2's gown had become shortened to the extent of showing his buttocks and legs.

C. 12/16/20 at 10:50 am during interview, V1 confirmed patient's buttocks and legs were exposed for approximately 10 minutes.

Based on record reviews of 5 patients (1, 2, 3, 8, and 10) of the 10 sampled patients chosen based on having had fallen during their hospital stay and interviews, the facility failed to provide care in a safe setting for their self-identified high risk fall population. This failed practice is likely to cause physical and psychological (emotional or behavioral) harm to the patients including extending the length of stay to a wide range of vulnerable patients, increasing the risk of mortality (untimely or unexpected death).

A. Record Review of facility's "Fall Prevention" Policy effective since 8/2012:

1. Patient's labeled as high risk for falling must have hourly rounds performed.

2. Patient's screened as high risk for falling should have consideration for safety alarm devices.

3. In regard to post fall care: "If a fall occurs, a comprehensive evaluation of the fall must be documented. The patient medical record will include an assessment of the patient's status, nature of injury if any and type of fall; physician and family notification and any intervention or treatment related to fall."


B. Record Review of Patient #1's Nursing assessment notes from 4/20/2020-4/28/2020:

1. On 4/20/2020 Patient had an unwitnessed fall at 7:19 pm "patient was found on floor by LPN (Licensed Practical Nurse) and states he hit his head" Nurse documents that an inspection of head was done, neurovascular assessment (assessment of orientation, level of consciousness, and capacity) that was done was not timed so unable to determine if done prior to or after fall. There is no documented rounding or fall safety checks (checking on the patient every hour to ensure safety and needs are still being met) from 12 pm- 6 pm, meaning it is unknown how long this patient was on the floor for.

2. Pt (Patient) is taking Plavix (blood thinning medication that has a higher risk of bleeding if a fall occurs)

3. On 4/21/2020 there is no documented hourly rounding or fall safety checks from 8 am to 5 pm.

4. On 4/22/2020 there is a variation of rounding and fall safety checks noted with at time of day shift rounding every 2 hours and night shift rounding every hour. 6:05 pm "Patient found on ground confused with initial blood pressure 75/35 (Very low Blood Pressure Normal is 130 to 140 / 70 to 80)." No documentation of family notification.

5. On 4/23/2020 hourly rounding and fall safety checks occur every 2 hours throughout both shifts. This patient already has fallen twice. It is expected for rounding to occur every hour for patients with frequent fall history.

6. On 4/24/2020 there is no documented hourly rounding or fall safety checks from 4 pm-6 am. At 7:10 pm "Patient found sitting on floor mat by bed with large bruise to left leg, unable to tell when this occurred." No documentation of bruising on leg from nursing assessment on 4/23/2020. No documentation of family notification.

7. On 4/26/2020 hourly rounding and fall safety checks occur every 2 hours. This patient has fallen 3 times.


C. Record Review of Patient #1's MD (Medical Doctor) Progress Notes from 4/19-4/22/2020:

1. Each note states "Per discussion with nursing, no events overnight or this morning" even though the patient had multiple falls since 4/22/2020.


D. Record Review of Patient #1's "Action Cue Event Report" ("Action Cue" is the facility's internal software to report adverse or unexpected events.) for events placed from 4/20/2020-4/26/2020:

1. Review of Fall Event on 4/20/2020 indicates "A fall huddle (meeting of staff to determine cause and implement meaningful interventions, this is to happen after every fall per policy) was not completed." and "fall prevention practices should have been in place based on admission risk assessment". The reviewer in conjunction with the approval of the CNO (Chief Nursing Officer) that secondarily reviewed this fall event report that the contributing causes to this fall as "failure to comply with culture of safety (Culture of safety relates to a proactive approach to the reduction of adverse events that can lead to harm) and fall risk intervention/supplies not involved."

2. Documented post incident review by Chief Nursing Officer for Fall event on 4/22/2020 states contributing factor to fall as "failure to comply with culture of safety".

3. Documented post incident review Chief Nursing Officer for Fall event on 4/24/2020 indicates "lack of completion of fall huddle, lack of care plan update and a new fall risk assessment post fall was not documented [in the patient's medical record.]."Furthermore, CNO indicates contributing factor as "Failure to comply with culture of safety".

4. Documented post incident review Chief Nursing Officer for Fall event on 4/26/2020 states contributing factor to fall as "failure to comply with culture of safety" .


E. Record Review of patient #3's Nursing assessment notes from 12/15/2020-12/16/2020:

1. Nurse indicates that patient fell about 2 days ago, but note was not found on 12/13/2020, and was screened as a high risk to fall.

2. On 12/16/2020 at 4:45 am note states "Patient was found on floor; bed exit alarm was off." In regard to post fall interventions, note states "Bed alarm turned on and hourly rounding increased".

3. Hourly rounding remained every 2 hours after fall. Hourly rounding frequency did not change.

4. No evidence of a nursing assessment done post fall.


F. Record Review of patient #3's MD progress note from 12/16/2020

1. States "Patient had a fall at 0400, patient currently reporting right rib pain."

2. No indication of right sided rib pain on nursing assessment or provider notification of status change.

3. X-Ray ordered by MD with no acute findings.


G. Record Review of Patient #2's nursing assessment notes from 12/7/2020-12/16/2020:

1. On 12/7/2020 at 1:15 am patient had an unwitnessed fall with no family notification documented.

2. On 12/8/2020 at 9:45 pm patient had an unwitnessed fall with no family notification documented.


H. Interview with Staff member #2 (Registered Nurse) on 12/17/2020 at 12:42 pm indicated that there was no definitive method to verify patient #2's care plan was updated after fall. Staff member #2 reinforced that a patient's fall risk needs that are to be discussed during IPOC/Team Conference Weekly Updates in order to formulate goals of care to prevent injury. Staff member #2 stated that during Weekly Updates, family input is to be included.


I. Record Review of patient #2's "IPOC/Team Conference Weekly Update" from 12/09/2020

1. No mention of fall precautions in goals of care, mobility, or safety. Patient had fallen on 12/08/2020.


J. Record Review of patient #2's "Nursing Care Plan" from 12/07/2020-12/08/2020

1. No evidence of care plan updated to reflect fall on 12/08/2020.


K. Record Review of Patient #10's Nursing assessment notes from 1/31/2020-2/7/2020:

1. On 2/1/2020 patient had a fall reported in "Action Cue" but documentation is not found in nursing notes.

2. On 2/2/2020 at 4:25 pm "patient found on floor next to bed, assessment done, provider and family notified."

3. On 2/7/2020 at 4 pm "patient fell OOB (out of bed), patient assessed. Action Cue done" No documentation of family or provider notification.


L. Record Review of Patient #10's MD Progress Notes from 1/31/2020-2/7/2020:

1. No mention of acute events or falls for any dates.


M. Record Review of Patient #8's nursing assessment notes from 5/29/2020 to 6/3/2020:

1. On 5/29/2020 at 9:45 am nursing note states that patient had a medication error "Patient received 1 gram of Cefepime (antibiotic, medication) instead of 2 grams of Ceftriaxone (antibiotic, medication). No documentation of family notification or if reported as adverse event.

2. Nursing note on 6/3/2020 at 900 am "Patient found on the floor" no assessment, no Physician notification, or family notification documented.


N. Record Review of Patient #8's "Action Cue Event Reports" from 5/23/2020 to 6/3/2020:

1. Event entered on 5/23/2020 indicates that patient fell "Found sliding from the bed and she is in a squatting position, and she has a big bowel movement, and her restraints still on" No documentation of family or provider notification.

2. Event entered on 5/25/2020 indicates that patient fell "Patient was found lying on her back with restraints still tied to her bed". No assessment, no Physician notification, or family notification documented.

3. Event entered on 6/3/2020 indicates that patient fell and the staff marked that the patient had hit their head (no investigation documented). This was overridden by facility's review manager (S#11 - Risk Manager) to indicate "No apparent injury" No documentation of family notification.


O. Interview with Staff member #9 (Nurse Practitioner) on 12/17/2020 at 11:35 am reinforced that the IPOC/Team Conference Weekly Updates are where plans of care are modified to keep goals of care customized to patient's needs. Staff member #9 also highlighted that if a fall occurred on night shift that the night shift Nurse Practitioner would have verbal orders inputted and give an informal report to the morning doctor during shift change. There is no documentation of this shift change taking place, but staff member #9 verbalized that they would expect documentation on a patient fall to be in the MD (Medical Doctor) Progress note.


P. Interview with Staff member #11 (Registered Nurse and Director) on 12/17/2020 at 1:04 pm indicated that the "Action Cue" reporting software is for tracking and quality improvement only. Staff member #11 reinforced that "Action Cue" is not part of a patient's medical record and that documentation of a fall should not solely be done in it.

Based on record reviews of 4 (Patient 1, 2, 3, and 8) out of 10 sampled patients chosen based on having had fallen during their hospital stay and interviews, the facility failed to keep nursing plans of care current and designed to meet high risk needs of fall prevention. The facility failed to prioritize this in any interdisciplinary meetings. This failed practice is likely to lead to fragmented care and ineffective interventions as care is not being customized to meet the needs of the individual patient.

The findings are:

A. Record review of facilities "Fall Prevention" policy effective since 08/2012

1. Step 4 on the documentation portion of the policy states if a patient has been screened as a high fall risk to: "document 'high risk for injury related to fall risk' on plan of care, with the initiation of the fall prevention protocol on the plan of care."


B. Record review of patient #1's "Action Cue" ("Action Cue" is the facility's internal software to report adverse or unexpected events.) Event Report forms from 04/24/2020:

1. Chief Nursing Officer's review of event comments "lack of care plan update and new fall risk assessment was not documented"


C. Record Review of patient #1's "IPOC/Team Conference Weekly Update" (IPOC- Individualized Plan of Care) from 04/20/2020-4/28/2020

1. Form from 4/21/2020 does not highlight fall precautions in goals of care, mobility, or safety, even though the patient had fallen on 4/20/2020.

2. Form from 4/28/2020 does not highlight fall precautions in goals of care, mobility, or safety. Patient has had multiple falls since this meeting.


D. Record Review of Patient #1's MD Progress Notes from 4/19-4/22/2020

1. Each note states "Per discussion with nursing, no events overnight or this morning" This is despite patient having had multiple falls since 4/22/2020. Patient fell 4/20, 4/22, 4/24, and 4/26.


E. Record Review of patient #2's "IPOC/Team Conference Weekly Update" from 12/09/2020

1. No mention of fall precautions in goals of care, mobility, or safety. Patient had fallen on 12/07/2020 and 12/08/2020.


F. Record Review of patient #2's "Nursing Care Plan" from 12/07/2020-12/08/2020

1. No evidence of care plan updated to reflect fall on 12/08/2020.


G. Interview with Staff member #2 (Registered Nurse) on 12/17/2020 at 12:42 pm indicated that there was no definitive method to verify patient #2's care plan was updated after fall when presented with it. Furthermore, Staff member #2 reinforced that a patient's fall risk needs are to be discussed during IPOC/Team Conference Weekly Updates in order to formulate goals of care to prevent injury.


H. Record Review of patient #3's Nursing assessment notes from 12/15/2020-12/16/2020:

1. Nurse indicates that patient fell about 2 days prior [12/13/2020] and was screened as a high risk to fall.

2 .On 12/16/2020 at 4:45 am note states "Patient was found on floor, bed exit alarm was off." In regards to post fall interventions, note states "Bed alarm turned on and hourly rounding increased"

3. Hourly rounding remained every 2 hours after fall. Hourly rounding frequency did not change.


I. Record Review of Patient #8's nursing assessment notes from 5/29/2020 to 6/3/2020:

1. On 5/29/2020 at 9:45 am nursing note states that patient had a medication error "Patient received 1 gram of Cefepime (antibiotic, medication) instead of 2 grams of Ceftriaxone (antibiotic, medication). No documentation of family notification or if reported as adverse event.

2. Nursing note on 6/3/2020 at 900 am "Patient found on the floor" no assessment, no Physician notification, or family notification documented.


J. Record Review of Patient #8's "Action Cue Event Reports" from 5/23/2020 to 6/3/2020:

1. Event entered on 5/23/2020 indicates that patient fell "Found sliding from the bed and she is in a squatting position, and she has a big bowel movement, and her restraints still on" No documentation of family or provider notification.

2. Event entered on 5/25/2020 indicates that patient fell "Patient was found lying on her back with restraints still tied to her bed". No assessment, no Physician notification, or family notification documented
3. Event entered on 6/3/2020 indicates that patient fell and the staff marked that the patient had hit their head (no investigation documented). This was overridden by facility's review manager (S#11 - Risk Manager) to indicate "No apparent injury" No documentation of family notification.


K. Interview with Staff member #9 (Nurse Practitioner) on 12/17/2020 at 11:35 am reinforced that the IPOC/Team Conference Weekly Updates are where plans of care are modified to keep goals of care customized to patient's needs. Staff member #9 also highlighted that if a fall occurred on night shift that the night shift Nurse Practitioner would have verbal orders inputted and give an informal report to the morning doctor during shift change. There is no documentation of this shift change taking place, but staff member #9 verbalized that they would expect documentation on a patient fall to be in the MD (Medical Doctor) Progress note.


L .Interview with Staff member #11 (Registered Nurse and Director) on 12/17/2020 at 1:04 pm indicated that the "Action Cue" reporting software is for tracking and quality improvement only. Staff member #11 reinforced that "Action Cue" is not part of a patient's medical record and that documentation of a fall should not solely be done in it.

Based on interview and observation the facility failed to maintain the integrity or replace the equipment which would prevent the spreading of infections or communicable diseases. This failed practice places patients at risk for exposure to infectious diseases while receiving treatment due to equipment not being maintained to ensure an acceptable level of safety and quality.

The findings are:

A. On 12/16/20 starting at 9:30 am during observation, the following was observed:

Room 301- Upon entering heard a loud hissing sound, interpreted as the air conditioning system. When S3 (Lead Respiratory Therapist) was asked to enter the room to confirm tears on the chair, S3 heard the hissing sound and noticed the call button line wrapped around a "Y" connection which was plugged into the oxygen port on the wall. Connected to the "Y" connection were two flow meters (instrument used to measure volumetric flow rate of a liquid or a gas). The hissing sound was oxygen leaking due to the weight of the call button line weighing down the "Y" connection.
Black bariatric (an oversized seating designed to support more than 300 pounds of evenly distributed weight) chair. Revealed left armrest rear seam unraveled and right armrest missing. Footrest has four square cushions (4 inches by 4 inches in diameter), top two cushions around all the edges and too many tears to list.

An electric tilt table used for therapy, revealed several vertical tears (approximately ½ inch to 1 inch in diameter) both top corners near the headrest area. A vertical tear (approximately 1 inch in diameter) near the footrest on the right side.


Room 305- Invacare (brand name) recliner, revealed a tear (approximately ½ inch in diameter) on the top left corner of the elbow rest, a tear (approximately ½ inch in diameter) on the right top corner of the elbow rest, and a vertical tear (approximately 3 ½ inches in diameter) in the seat area.

Room 314- Invacare recliner, revealed a tear (approximately 2 inches in diameter) on seam on the top portion of the right armrest where the hand rests.

Room 319- Invacare recliner, revealed a tear (approximately ½ inch in diameter) on the left armrest top corner, and a tear (approximately 1 inch in diameter) on the right armrest top portion where the arm rests and the rear seam unraveled.

Room 320- Invacare recliner, revealed a tear (approximately ¾ inch in diameter) on the right armrest, a vertical tear (approximately ½ inch in diameter) in the seat area, and the left armrest rear seam unraveled. Another chair in the same room revealed the left armrest rear seam unraveled, a tear (approximately 1 inch in diameter) on the top of the footrest, a tear (approximately 18 inches in diameter) on the side seam of the right armrest.

Room 323- revealed the mattress had 3 of the 4 corner seams unraveled, two tears, one (approximately 1 inch in diameter) and the other (1/2 inch in diameter) on the left side of mattress. The center of mattress indented to where there was no back support if a patient were to lay on the mattress, the lining of the mattress faded (because of the disinfectant solution used to clean). Dark orange stains on mattress (appeared to be from a medical solution to treat wounds).

B. On 12/16/20 at 10:05 am during interview, S2 (RN Case Manager) confirmed the tears on the electric tilt table in room 301.

C. On 12/16/20 at 10:20 am during interview, S3 (Lead Respiratory Therapist) confirmed the tears on the seat area, footrest, and the armrest missing on the bariatric chair in room 301. S3 confirmed the bariatric chair is in use to transport patients and if family members wish to stay, can sleep on it.

D. On 12/16/20 at 10:25 am during interview, S3 and S6 (Housekeeping) confirmed oxygen had been leaking for approximately 1 ½ hours in room 301 when S6 wrapped the call button line around the "Y" connection while cleaning the room earlier that morning.

E. On 12/16/20 at 10:45 am during interview, S6 confirmed when cleaning an empty patient room will hang the call button line on the panel wall system (integrated electrical raceways and conduit, providing a single area connection), so the call button line is not on the ground.

F. On 12/16/20 at 10:50 am during interview, S6 confirmed the tears, indentation, dark orange stains on the mattress in room 323, and the tears on the other chairs in all the other rooms.