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Based on record review, policy review, document review and interview the hospital failed to ensure they met the requirements for the Nursing Services Condition of Participation by nursing staff not following hospital policy and procedure.

The cumulative effects of nursing staffs failure to follow the hospitals Fall Prevention Protocol policy; failure to update the Initial Safety Plans/Nursing Care Plans with intervention following patient falls; and failure to ensure all agency staff are educated on the policies and procedures of the hospital places patients at an increased risk for additional falls resulting in harm or injury.


Findings Include:


1. The hospital failed to ensure nursing staff followed the Fall Prevention Protocol policy, for 6 of 10 patient (Patient 1, 2, 3, 5, 8, and 9) records reviewed. Refer to A0395

2. The hospital failed to ensure the Initial Safety Plan/Nursing care plan was updated with interventions and measurable goals following falls for 7 of the 10 patients (Patient 1, 2, 3, 4, 5, 8, and 9) medical records reviewed. Refer to A0396

3. The hospital failed to ensure and provide evidence agency nursing staff were educated on policies and procedures of the hospital. Refer to A0398

Based on record review, policy review, document review and interview the hospital failed to ensure nursing staff followed the Fall Prevention Protocol policy, for 6 of 10 patient (Patient 1, 2, 3, 5, 8, and 9) records reviewed. Failure of the nursing staff to follow the Fall Prevention Protocol policy places patients at risk for falls with injury, which can delay the patients' recovery and extend the length of hospitalization for all patients in the facility.


Findings Include:


1. Review of the facility policy titled, "Fall Prevention Protocol" revised 05/2022 showed " ... ... Post Fall Follow Up: ...Assess patient (vital signs and patient response to fall) and document circumstances of the fall and the patient assessment in the patient health record. Notify the physician of the fall and document in patient health record ...Complete a skin assessment w/in (1) hour of the patient falling to assess for any redness, swelling, bruising or active bleeding. A neurological assessment will be completed for all unwitnessed falls and those involving patient hitting their heads ... ... Complete Post Fall Assessment (located under nursing assessments) Care plan updated with new intervention ... ...Nurses are to document a nursing narrative note at the time of the incident and every shift for at least 72 hours post fall describing patient condition and improvement or decline with interventions put in place. A medication review will be completed with the Medical Provider, Psychiatric or Designee and Administrator post fall. This will be documented in the nursing narrative notes by the Administrator or Designee. ...Reporting Patient Falls, Patient falls must be reported through the standard incident reporting (Utilize Incident report for Falls) process and submitted to the Director of Nursing ...


Patient 1

Review of Patient 1's discharged medical record showed an admission date of 03/04/22 with diagnoses of Alzheimer's disease (a brain disorder that causes problems with memory, thinking and behavior) and Obsessive-Compulsive Disorder (mental health disorder characterized by repetitive actions that seem impossible to stop).

Review of an document titled, "Incident Report Form" showed, the date of the incident 03/08/22 at 12:30 AM, "At 0023 (12:23 AM) when I was doing routine round, I found pt (patient) on the floor near by her bed, pt had unwitnessed fall ... There was no signature on the Incident Report Form.

Review of Patient 1's "Nursing Narrative" note dated 03/08/22 and electronically signed at 6:16 AM, by Staff N, RN, failed to show documentation of Patient 1's fall that occurred on 03/08/22 at 12:30 AM. Further review of the Nursing Narrative showed, Patient 1 was difficult to redirect an order was received to give Geodon (medication is used to treat certain mental/mood disorders) 20 mg injection and at 2:00 AM Staff N documented, no change in status, patient sitting in bed, talking to unknown others, will continue to monitor.

During an interview on 08/16/22 at 11:00 AM, Staff N, Agency RN, stated that she wasn't sure if she remembered this patient, however after describing the date, incident and medication Patient 1 received she stated that she wrote it manually on paper, not on the computer. She stated that she completed an incident report and neuro checks. Even though Staff N stated that she completed documentation and neurochecks related to the fall on 03/08/22 at 12:30 AM, there was no evidence in the medical reord that they were completed.

Nursing staff failed to follow the Fall Prevention Protocol policy by not implementing new interventions following the fall on 03/08/22 at 12:30 AM; failed to document in the nursing narrative note that Patient 1 fell on 03/08/22 at 12:30 AM, failed to provide evidence the neuro checks were completed for the unwitnessed fall, failed to complete an incident report, and failed to document a post fall assessment describing patient condition and improvement or decline with interventions put in place. Failure to follow the Fall Prevention Protocol policy resulted in Patient 1 falling again on 03/08/22 at 8:48 AM.

Review of Patient 1's "Nursing Narrative" note dated 03/08/22 and last modified at 1:55 PM by Staff B, Registered Nurse (RN), showed at 6:45 AM, ..."Nurse receives in report that pt had an unwitnessed, non-injury fall that that (sic) occurred 03/08/2022 at 0030 (12:30 AM). ... At 8:48 AM the note showed that Patient 1 was found on the floor in an adjacent empty room, she complained of pain in her right hip, 911 was called and she was transferred to an acute care hospital. The fall resulted in a fractured hip and sacrum.


Patient 2

Review of Patient 2's discharged medical record showed an admission date of 05/06/22 with an admission diagnosis of unspecified psychosis (a disconnection from reality) not due to a substance or known physiological condition, Mood Disorder (characterized by elevation or lowering of a person's mood), and Encephalopathy (disease, damage, or malfunction of the brain). Additional diagnoses include delusional disorder (a disorder where a person has trouble recognizing reality).

Review of Patient 2's "Nursing Narrative Note" dated 05/09/22 by Staff U, RN, showed Patient 2 tripped over another patient and then fell at 7:30 PM. The fall was witnessed with no injuries and showed "two witnesses confirm no head injury."

Nursing staff failed to follow the Fall Prevention Protocol policy by not completing a Post Fall Assessment; failed to update the Initial Safety Care plan with new interventions following the fall; failed to document in the nursing narrative notes a description of the patient's condition and improvement or decline with interventions put in place for at least 72 hours post fall; and there was no documented evidence in the nursing narrative notes by the Administrator or Designee indicating that a medication review was completed post fall.

Review of Patient 2's "Nursing Narrative Note" dated 05/12/22 by Staff Z, RN showed that at 9:00 AM, "Patient continues to be on line of sight while awake" ... at 5:30 PM, "Dinner served patient tried to grab another patients (sic) walker and turned around, tripped on a chair, lost balance and fell. MHA [Mental Health Aide] [name] witnessed the fall. No injury suffered nor bruises, Patient didn't hit his head and no complains (sic) of pain" ...

Nursing staff failed to follow the Fall Prevention Protocol policy by not completing an incident report for this fall and failed to complete a Post Fall Assessment.

Review of Patient 2's "Nursing Narrative Note" dated 05/13/22 by Staff V, RN, at 8:23 PM showed that Patient 2 attempted to get out his chair at lunch and lost his balance and fell to the floor. Further review showed that a few minutes later he fell again; hitting his head against the wall.

Nursing staff failed to follow the Fall Prevention Protocol policy by not completing a Post Fall Assessment; failed to update the Initial Safety Care plan with new interventions following the fall; failed to document in the nursing narrative notes a description of the patient's condition and improvement or decline with interventions put in place for at least 72 hours post fall; and there was no documented evidence in the nursing narrative notes by the Administrator or Designee indicating that a medication review was completed post fall.

Review of Patient 2's "Nursing Narrative Note" dated on 05/16/22 by Staff W, RN showed Patient 2 fell at 1:30 PM, "Patient was in the commons area, he was sitting with staff, patient stood up to stretch, he lost his balance and he had a fall." Further review of the narrative note showed Patient 2 was sent to a hospital for evaluation related to his frequent falls.

Nursing staff failed to follow the Fall Prevention Protocol policy by not completing a Post Fall Assessment; failed to update the Initial Safety Care plan with new interventions following the fall; and there was no documented evidence in the nursing narrative notes by the Administrator or Designee indicating that a medication review was completed post fall.


Patient 3

Review of Patient 3's discharge medical record showed an admission date of 05/11/22 with chief complaint of harm to others, agitation, refusing medications, MDD (Major depressive disorder, and dementia without behaviors. The admitting diagnosis was unspecified psychosis not due to substance or know physiological condition.

Review of Patient 3's "Nursing Narrative Note" dated 05/13/22, by Staff Y, RN showed at 1:00 PM, "During lunch patient became agitated and belligerent with staff. Pt was unable to redirect. Pt began throwing food and swinging arms with up out of wheelchair and fell on side to the floor. No apparent injury."

Review of Patient 3's "Nursing Narrative Note" dated 05/31/22 by Staff Y, RN showed, at 12:00 PM, Pt. sitting CA (common area) in WC (wheelchair). Pt. attempted to sit on the edge of WC seat and fell to the floor on his buttocks. No apparent injury.

Review of Patient 3's incident reports and documents titled "Supervisor Incident Investigation Report" showed:

05/13/22 at 1:35 PM: Patient 3 stood up, lost his balance, and fell. The fall was witnessed by staff. "Pt struggles with impulse control and safety awareness, Incident report was completed on 05/14/22. Prevention measures for Root Cause and Contributing Causes included: Patient 3 observations was increased to Line of Sight (LOS).

05/16/22 at 8:40 AM: unwitnessed fall, found on floor next to bed without pants. Attempting to dress independently. Prevention measures for Root Cause and Contributing Causes included: Purposeful rounding, offer toileting, encourage coming to common area.

05/31/22 at 12:00 PM: witnessed fall, scooted to edge of wheelchair, slid off landed on buttocks.

06/01/22 at 7:00 PM: Attempting to stand up from wheelchair and began falling, staff tried to stop the fall, wheelchair not locked. Pt forgets limits.

Nursing staff failed to follow the Fall Prevention Protocol policy by not completing a Post Fall Assessment; failed to update the Initial Safety Care plan with new interventions following each fall and failed to document in the nursing narrative notes a description of the patient's condition and improvement or decline with interventions put in place for at least 72 hours post fall.


Patient 5

Review of Patient 5's discharge medical record showed an admission date on 06/23/22 with chief complaint of aggression both verbal and physical, paranoia and anxiety. The admitting diagnosis was unspecified Psychosis with Dementia.

Review of Patient 5's incident report and document titled "Supervisor Incident Investigation Report" completed on 07/25/22 showed, Patient 5 fell on 07/24/22 at 6:55 PM: Pt found on the floor in front of room 401 on her knees on mat. Prevention measures for Root Cause and Contributing Causes included: Reoriented to what door mats were, Medication adjustment monitored by providers until discharge 07/25/22, Intentional rounding to anticipate needs until discharge.

Nursing staff failed to follow the Fall Prevention Protocol policy by not updating the Initial Safety Care plan with new interventions following the fall and failed to document in the nursing narrative notes a description of the patient's condition and improvement or decline with interventions put in place for at least 72 hours post fall.


Patient 8

Review of Patient 8's current medical record showed an admission date of 07/15/22 with a chief complaint of paranoid schizophrenia (a mental disease that has debilitating symptoms that blurs the line between what is real and what isn't), hypersexual, depression, dementia and suicidal ideation without a plan.
Review of Patient 8 "Nursing Narrative" note showed a fall on 07/22/22 at 1:40 PM, "Pt was walking in the commons area holding on railing and fell flat to the ground on right side of body. ...No apparent injuries noted.

Review of Patient 8's incident report and document titled "Supervisor Incident Investigation Report" completed on 08/03/22 showed a fall on 08/02/22 at 3:50 PM. Patient 8 was hallucinating and swat at things that he seen. The fall was witnessed. The new interventions listed on the incident report: medication management to assist with sleep and anxiety. Close observation while having anxiety.

Nursing staff failed to follow the Fall Prevention Protocol policy by not completing an incident report for the fall on 07/22/22, by not updating the Initial Safety Treatment Plan with new interventions and failed to document in the nursing narrative notes a description of the patient's condition and improvement or decline with interventions put in place for at least 72 hours post fall.


Patient 9

Review of Patient 9's medical records show an admission date of 07/25/22 with a chief complaint of agitation, physical aggression, refusing medications, refusing care, and anxiety. The admitting diagnosis was unspecified Psychosis with agitation, suicidal ideation with a plan, anxiety, and dementia.

Review of Patient 9's "Nursing Narrative" note showed a fall documented in a nursing narrative note on 07/31/22 at 8:30 AM. "Patient 9 was found on the floor bedside bed. Patient 9 was sitting upright, the Pt had redness on right hip and hip was tender to touch.

Nursing staff failed to follow the Fall Prevention Protocol policy by not completing a Post Fall Assessment; and failed to update the Initial Safety Care plan with new interventions following the fall.


During an interview on 08/10/22 at 11:24 AM, Staff A RN, Director of Nursing (DON) stated that documentation of the post fall assessment is not followed if the fall in a non-injury fall.

During an interview on 08/10/22 at 4:55 PM, Staff B RN, Charge Nurse stated that the policy when they have a fall is, they will complete an immediate nursing assessment. If the fall was witnessed and non-injury the nurse would call the doctor, notify family and complete incident report. If the fall was unwitnessed then the nurse would complete an assessment, obtain vital signs and complete neurological checks for 15 min for an hour, 30 min for an hour, then every hour, then every 4 hours. The nurses use a separate neurological check form. The provider, family and nursing management are notified, and a Post Fall Assessment is completed for 72 hours. Fall interventions are implemented by the nurse and documented in a nursing narrative.

Based on record review, policy review, and interview, the hospital failed to ensure the Initial Safety Plan (nursing care plan) was updated with interventions (prevention measures) and measurable goals following falls for 7 of the 10 patients (Patient 1, 2, 3, 4, 5, 8, and 9) medical records reviewed. Failure to keep the nursing care plans current has the potential for care needs to not be identified or implemented which can delay the patients' recovery and extend the length of hospitalization for all patients in the facility.


Findings Include:


Review of the facility policy titled, "Multidisciplinary Treatment Plan," revised 07/2022 showed, "...5. Every patient's plan of care shall identify short term and long-term patient goals and associated objectives and interventions necessary to meet the identified goals. 6. The Initial Treatment Plan will be started upon admission which is the Nursing Care Plan (which is a part of the Master Multidisciplinary Plan). 7. The master treatment plan includes: a ...Goals must be written as observable, measurable patient behaviors to be achieved ... 8. Progress toward care goals will be updated weekly by Nursing staff.


Patient 1

Review of Patient 1's discharged medical record showed an admission date of 03/04/22 at 12:28 PM with diagnoses that included Alzheimer's disease (a brain disorder that causes problems with memory, thinking and behavior) and Obsessive-Compulsive Disorder (mental health disorder characterized by repetitive actions that seem impossible to stop).

Review of Patient 1's "Edmonson Psychiatric Fall Risk Assessment" (EPFRA) dated 03/04/22 at 9:49 PM, showed a fall risk score of 82 indicating Patient 1 was a moderate risk for falls. (EPFRA scoring: Low Risk 0-74, Moderate Risk: 75-99, High Risk 101 and above). Patient 1's EPFRA showed she was a moderate fall risk throughout her stay with a score ranging from 81 to 87.

Review of Patient 1's "Initial Safety Treatment Plan" (Nursing Care Plan), showed an active problem list that included 1. Dementia with Behaviors" Interventions included, "Staff will use therapeutic communication to access (sic) [Patient 1's] needs, provide gentle reorientation and redirection as needed; 2. "High Fall" with a recorded date of 03/04/22. The problem list showed, "As Evidenced By", Updated post fall 03/08/22: [Patient 1] hand an unwitnessed non-injury fall early morning on 03/08/22, she then had a fall late morning same day." The Interventions showed, "Staff will increase safety checks to 10 minutes, encourage [Patient 1] to participate in groups and remain awake. Staff will encourage use of non-skid socks"; 3."Anxiety" interventions included, Staff will check on [Patient 1] every 15 minutes with the purpose of providing comfort and attending to needs and concerns to decrease anxiety and provide reassurance; and 4. "Insomnia" interventions included, Staff will provide a peaceful nightly wind down, administer trazadone as ordered.

Review of a document titled, "Incident Report Form" showed, the date of the incident 03/08/22 at 12:30 AM, "At 0023 (12:23 AM) when I was doing routine round, I found pt on the floor near by her bed, pt had unwitnessed fall" ... There was no signature on the Incident Report Form.

Review of Patient 1's "Nursing Narrative" note dated 03/08/22 and electronically signed at 6:16 AM, by Staff N, RN, failed to show documentation of Patient 1's fall that occurred on 03/08/22 at 12:30 AM.

Further review of the "Initial Safety Treatment Plan" (Nursing Care Plan) showed the plan failed to show updated interventions following the first fall on 03/08/22 at 12:30AM or included any observable, measurable goals for the problems listed in Patient 1's Initial Safety Care Plan.


Patient 2

Review of Patient 2's discharged medical record showed an admission date of 05/06/22 with an admission diagnosis of unspecified psychosis (a disconnection from reality) not due to a substance or known physiological condition, Mood Disorder (characterized by elevation or lowering of a person's mood), and Encephalopathy (disease, damage, or malfunction of the brain). Additional diagnoses include delusional disorder (a disorder where a person has trouble recognizing reality).

Review of Patient 2's EPFRA showed a score range of 45-89 for the dates of 05/06/22 through 05/13/22, indicating a low to moderate risk for falls and 102-107 from 05/14/22 through 05/16/22, indicating a high risk for falls.

Review of the "Initial Safety Treatment Plan" (Nursing Care Plan) showed a recorded date of 05/06/22, Patient 2 was a low fall risk and he walks without assistance. The short-term goal showed Patient 2 would be free of falls while admitted. The interventions included: Patient 2 will wear nonskid footwear while walking, encourage time spent in commons area while awake. Staff will monitor every 15 minutes and address any needs or wants.

Review of Patient 2's "Nursing Narrative Note" dated 05/09/22 by Staff U, RN, showed Patient 2 tripped over another patient and then fell at 7:30 PM.

Review of an incident report and a document titled, "Supervisor Incident Investigation Report" completed on 05/10/22 showed patient fell on 05/09/22; two patients collided while one was being redirected. Prevention measures for Root Cause and Contributing Causes showed "Staff to monitor for surrounding patients when de-escalating/redirecting other patients-D/C (discontinue)-post incident."

Review of Patient 2's "Nursing Narrative Note" dated 05/12/22 by Staff Z, RN, showed ... at 5:30 PM, "Dinner served patient tried to grab another patients (sic) walker and turned around, tripped on a chair, lost balance and fell.

There was no incident report provided for this fall that occurred on 05/12/22.

Review of Patient 2's "Nursing Narrative Note" dated 05/13/22 by Staff V, RN, showed at 12:45 PM, Patient 2 attempted to get out his chair at lunch and lost his balance and fell to the floor. Further review showed that a few minutes later he fell again; hitting his head against the wall.

Review of Patient 2's incident report and a document titled, "Supervisor Incident Investigation Report" completed on 05/14/22 showed patient fell twice on 05/13/22. Prevention measures for Root Cause and Contributing Causes showed "Medication adjustments monitored by providers while receiving tx (treatment)" and "Upgraded from line of sight to 1:1 by nursing staff until improved safety awareness."

Review of Patient 2's "Nursing Narrative Note" dated on 05/16/22 by Staff W, RN, showed Patient 2 fell at 1:30 PM, "Patient was in the commons area, he was sitting with staff, patient stood up to stretch, he lost his balance and he had a fall."

Review of Patient 2's incident report and a document titled, "Supervisor Incident Investigation Report" completed on 05/17/22, showed patient fell on 05/16/22 while staff attempted to help Patient 2 stand from his chair. Prevention measures for Root Cause and Contributing Causes showed "Medication adjustments monitored by providers while receiving treatment 05/17/22" and "Sent to ER to eval and tx due to frequent falls and weakness."

Further review of the "Initial Safety Treatment Plan" (Nursing Care Plan) showed nursing staff failed to update the plan with prevention measures identified in the Root Cause and Contributing Causes and the short-term goal was not revised or updated following each fall. The plan failed to show progress toward care goals were updated weekly by nursing staff.


Patient 3

Review of Patient 3's discharge medical record showed an admission date of 05/11/22 with chief complaint of harm to others, agitation, refusing medications, MDD (Major depressive disorder, and dementia without behaviors. The admitting diagnosis was unspecified psychosis not due to substance or know physiological condition.

Review of Patient 3's EPFRA showed a score 84-99 on 05/12/22 through 05/21/22 indicating a moderate risk for falls and 102-128 from 05/22/22 through 06/03/22, indicating a high risk for falls.

Review of Patient 3's "Initial Safety Treatment Plan" (Nursing Care Plan) dated 05/11/22 showed an active problem list that included 1. High Fall Risk, interventions for fall prevention include Nonskid footwear while ambulating, observe every 15 minutes, wake hours in the commons area, provide safe environment, redirect, deescalate, establish therapeutic treatment plan. Short term goal: Patient 3 will be free of falls.

Review of Patient 3's "Nursing Narrative Note" dated 05/13/22, by Staff Y, RN showed at 1:00 PM, "During lunch patient became agitated and belligerent with staff. Pt was unable to redirect. Pt began throwing food and swinging arms with up out of wheelchair and fell on side to the floor. No apparent injury."

Review of Patient 3's "Nursing Narrative Note" dated 05/31/22 by Staff Y, RN showed, at 12:00 PM, Pt. sitting CA (common area) in WC (wheelchair). Pt. attempted to sit on the edge of WC seat and fell to the floor on his buttocks. No apparent injury.

Review of Patient 3's incident reports and documents titled "Supervisor Incident Investigation Report" showed:

05/13/22 at 1:35 PM: Patient 3 stood up, lost his balance, and fell. The fall was witnessed by staff. "Pt struggles with impulse control and safety awareness, Incident report was completed on 05/14/22. Prevention measures for Root Cause and Contributing Causes included: Patient 3 observations was increased to Line of Sight (LOS).

05/16/22 at 8:40 AM: unwitnessed fall, found on floor next to bed without pants. Attempting to dress independently. Prevention measures for Root Cause and Contributing Causes included: Purposeful rounding, offer toileting, encourage coming to common area.

05/31/22 at 12:00 PM: witnessed fall, scooted to edge of wheelchair, slid off landed on buttocks.

06/01/22 at 7:00 PM: Attempting to stand up from wheelchair and began falling, staff tried to stop the fall, wheelchair not locked. Pt forgets limits.

Further review of the "Initial Safety Treatment Plan" (Nursing Care Plan) showed nursing staff failed to update the plan with prevention measures identified in the Root Cause and Contributing Causes and the short-term goal was not revised or updated following each fall.


Patient 4

Review of Patient 4's discharged medical record showed an admission date of 06/03/22 at 12:31 PM with diagnoses unspecified dementia with behavioral disturbances.

Review of Patient 4's EPFRA showed fall risk scores ranged from 89 to 137 indicating he was a moderate to high fall risk throughout his stay.

Review of Patient 4's "Initial Safety Treatment Plan" (Nursing Care Plan), showed an active problem list that included, 1. Low fall risk with interventions that included, "Patient will wear non-skid socks will (sic) mobile, she (sic) will ask for assistance when needed, staff will anticipate needs and monitor every 15 minutes, staff will encourage patients to spend wake hour in the commons area ...

Review of a "Nursing Narrative" note created on 06/19/22 at 11:39 PM by Staff Q RN, and signed on 06/20/22 at 6:04 AM, showed Patient 4 ..."was pulling his mattress out of his room and dragging it to his common area, and then the MHA (Mental Health Aide) was trying to take the mattress back to his room for safety. He threw himself against the mattress and fell. The fall was witnessed, and he did not hit his head." ...

Review of Patient 4's incident report and a document titled, "Supervisors Incident Investigation Report" Root Cause of the Incident dated 06/19/22 showed, "Patient becomes agitated and has violent behaviors." Prevention measures for Root Cause and Contributing Causes included: 1. Medication adjustment by provider - current, 2. Use (sic) monitoring when patient is in his room. 3. Encourage pt to spend wake hours in commons area.

Further review of the "Initial Safety Treatment Plan" (Nursing Care Plan) showed nursing staff failed to update the plan with prevention measures identified in the Root Cause and Contributing Causes and the short-term goal was not revised or updated following Patient 4's fall.


Patient 5

Review of Patient 5's discharge medical record showed an admission date on 06/23/22 with chief complaint of aggression both verbal and physical, paranoia and anxiety. The admitting diagnosis was unspecified Psychosis with Dementia.

Review of Patient 5's EPFRA showed fall risk scores ranged from 79 to 145 indicating she was a moderate to high fall risk throughout her stay.

Review of Patient 5's initial safety treatment plan/nursing care plan dated 06/23/22 "High Fall Risk with interventions; Pt will wear nonskid socks while mobile, ask for assistance when needed, staff will anticipate needs, staff will encourage Pt to spend wake hours in the common area, staff will monitor every 15 minutes and anticipate needs. The short-term goal Pt will be free of falls while admitted ..."

Review of Patient 5's incident report and document titled "Supervisor Incident Investigation Report" completed on 07/25/22 showed, Patient 5 fell on 07/24/22 at 6:55 PM: Pt found on the floor in front of room 401 on her knees on mat. Prevention measures for Root Cause and Contributing Causes included: Reoriented to what door mats were, Medication adjustment monitored by providers until discharge 07/25/22, Intentional rounding to anticipate needs until discharge.

Further review of the "Initial Safety Treatment Plan" (Nursing Care Plan) showed nursing staff failed to update the plan with prevention measures identified in the Root Cause and Contributing Causes and the short-term goal was not revised or updated following the fall.


Patient 8

Review of Patient 8's current medical record showed an admission date of 07/15/22 with a chief complaint of paranoid schizophrenia (a mental disease that has debilitating symptoms that blurs the line between what is real and what isn't), hypersexual, depression, dementia and suicidal ideation without a plan.

Review of Patient 8's EPFRA showed fall risk scores ranged from 81 to 120 indicating he was a moderate to high fall risk.

Review of Patient 8's "Initial Safety Treatment Plan" (Nursing Care Plan) dated 07/15/22 "Moderate Fall Risk with interventions; Staff will encourage the use of nonskid socks. Staff will anticipate her needs and monitor every 15 min. Staff will encourage patient to spend wake hours in the common areas." The short- term goal showed, Pt will be free of falls while admitted.

Review of Patient 8 "Nurse Narrative Note" showed a fall on 07/22/22 at 1:40 PM, "Pt was walking in the commons area holding on railing and fell flat to the ground on right side of body. ...No apparent injuries noted.

Review of Patient 8's incident report and document titled "Supervisor Incident Investigation Report" completed on 08/03/22 showed a fall on 08/02/22 at 3:50 PM. Patient 8 was hallucinating and swat at things that he seen. The fall was witnessed. The new interventions listed on the incident report: medication management to assist with sleep and anxiety. Close observation while having anxiety.

Further review of the "Initial Safety Treatment Plan" (Nursing Care Plan) showed nursing staff failed to update the plan with prevention measures identified in the Root Cause and Contributing Causes and the short-term goal was not revised or updated following each fall.


Patient 9

Review of Patient 9's medical record showed an admission date of 07/25/22 with a chief complaint of agitation, physical aggression, refusing medications, refusing care, and anxiety. The admitting diagnosis was unspecified Psychosis with agitation, suicidal ideation with a plan, anxiety and dementia.

Review of Patient 9's "Initial Safety Treatment Plan" (Nursing Care Plan) dated 07/25/22 showed, "High Fall Risk with interventions: Staff will encourage the use of nonskid socks while ambulating. Staff will anticipate her needs and monitor every 15 minutes. Staff will encourage patient to spend wake hour in the common areas. Staff will provide line of sight (LOS) level of observation." The short-term goal Pt will be free of falls while admitted.

Review of Patient 9's EPFRA showed fall risk scores ranged from 79 to 153 indicating she was a moderate to high fall risk.

Review of Patient 9's "Nurse Narrative Note" dated 07/31/22, showed Patient 9 fell at 8:30 AM. "Patient 9 was found on the floor bedside bed. Patient 9 was sitting upright, the Pt had redness on right hip and hip was tender to touch. Review of medical records showed that Staff P, Advanced Practice Registered Nurse (APRN) notified of fall and ordered one to one close observation.

Further review of the "Initial Safety Treatment Plan" (Nursing Care Plan) showed nursing staff failed to update the plan with prevention measures identified in the Root Cause and Contributing Causes and the short-term goal was not revised or updated following the fall.


During an interview on 08/10/22 at 11:16 AM, the Staff A, DON stated that nurses don't update the care plan, and that only she does. She stated that she doesn't necessarily date what she adds to the care plan. She stated that the care plan would be implemented by the nurses, but she would add to the care plan later, though they should document what intervention were done in the Nursing Narrative notes. She stated that post fall documentation should also reflect what interventions they put into place as well as the nurse would contact her and would be provided education.

During an interview on 08/15/22 at 8:15 AM, Staff K, RN, was asked what her responsibility was to update the care plans and she stated that she doesn't recall ever updating interventions in the care plans.

During an interview on 08/15/22 at 12:20 PM, Staff L, RN, was asked what her responsibility was to update the care plans, she stated that she has not updated patient care plans, and updates would be sporadic based on the patient's needs.

During an interview on 08/15/22 at 12:58 PM, Staff B, RN Charge Nurse, stated that Staff A, DON is currently responsible for updating care plans with new interventions.

During an interview on 08/16/22 at 10:30 AM, Staff A, DON clarified that the Initial Safety Plan is the Nursing Care Plan. When asked why she does not have the nurses update the care plans she stated that she "came in to it" and tried to delegate it to the assistant director of nursing (ADON) (no longer an employee), when asked about a time line for updating the CP she stated that she tries to get them done as soon as possible.

Based on record review, policy review, document review and interview the hospital failed to ensure and provide evidence agency nursing staff were educated on policies and procedures of the hospital. Failure to ensure agency nursing staff are educated on hospital policies and procedures has the potential to place patients at risk for care that doesn't meet the hospitals standards and expectations.


Findings Include:


Review of Staffing Agency A's contract signed 03/17/22 by Staff AA, Chief Executive Officer (CEO) showed, ...The Roles/Responsibilities of the Client: ...2. Provide orientation which, at minimum, includes review of policies and procedures regarding medication administration, documentation procedures, patient rights, Infection Prevention, and Fire and Safety, OSHA (Occupational Safety and Health Administration) and EMR (Electronic Medical Record)/Charting (if applicable) ...

Review of Staffing Agency B's contract signed 09/09/21 by Staff AA, CEO, showed, ...Obligation of Facility ...Facility will orient Employees to the Facility and its rules and regulations, including the physical layout and equipment on any unit to which such Employee is assigned.

During an interview on 08/11/22 at 1:43 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she does not keep personnel files for agency staff. She stated that there is a checklist about the hospital that each new agency staff has to do and go through with hospital staff upon arrival.

During an interview on 08/11/22 at 3:45 PM, Staff J, Staff Agency A, License Practical Nurse (LPN) stated that she received orientation on the system that is used to pass medications and to chart. The fall prevention policy when a patient has a fall is to complete an incident report, obtain vital signs, and assess for any level of conscious changes. Assist the patient with getting up, check for injury, notify the Director of Nursing, the provider and notify the family.

During an interview on 08/15/22 at 3:00 PM, Staff M, Staffing Agency A, LPN, when asked about orientation received related to fall policies, stated that she didn't receive orientation on falls but from her previous experiences she knew an assessment, checking for injuries, and neuro checks if the patient hit their head or was an unwitnessed fall, would need to be completed. Staff M stated that there was a notebook with policies in the nurse's station and that if she had any questions, she could call the DON.

The hospital failed to provide any documented evidence of orientation to the hospitals policies and procedures for agency nursing staff and failed to provide checklists completed by agency staff that included medication administration, documentation procedures, patient rights, Infection Prevention, Fire and Safety, OSHA and EMR/Charting (if applicable) ...

Based on record review, and policy review, and interview it was determined the hospital failed to ensure the initial psychiatric evaluations were conducted by a physician for 8 (Patients 1, 2, 3, 4, 6, 7, 9, and 10) of 10 medical records reviewed. Failure to ensure the initial psychiatric evaluation is conducted by the physician has the potential to place patients at risk for not receiving information from the psychiatrist regarding their hospitalization and treatment.


Findings Include:


Review of the hospitals Patient Handbook, undated, showed, "Patient Care Team" " A patient's care team includes a Psychiatrist, Licensed Nurse, Licensed Social Worker, Certified Music Therapist, and Certified Nursing Assistant" ... ..."The Psychiatrist meets with patients on a regular basis to provide information about his or her diagnoses, medications and discuss other relevant concerns regarding their hospitalization and treatment" ...

Review of the hospital policy titled, "Assessment and Reassessment," last revised 02/2022, indicated, each patient admitted to the institution shall receive a complete assessment by a qualified individual so that a plan of care can be developed to best meet the needs of the patient ...


Patient 1

Review of Patient 1's medical record showed an admission date of 03/04/22 at 12:28 PM with diagnoses that included Alzheimer's disease (a brain disorder that causes problems with memory, thinking and behavior) and Obsessive-Compulsive Disorder (mental health disorder characterized by repetitive actions that seem impossible to stop). Further review of the medical record showed Staff F, Advanced Practice Registered Nurse (APRN) conducted the initial psychiatric evaluation for Patient 1 on 03/06/22 at 12:29 PM. There was no evidence that the evaluation was reviewed, conducted, and/or signed by the psychiatrist.


Patient 2

Review of Patient 2's medical record showed an admission date of 05/06/22 with an admission diagnosis of unspecified psychosis (a disconnection from reality) not due to a substance or known physiological condition. Further review of the medical record showed Staff P, APRN conducted the Initial Psychiatric Evaluation on 05/07/22. There was no evidence that the evaluation was reviewed, conducted, and/or signed by the psychiatrist.


Patient 3

Review of Patient 3's medical record showed an admission date of 05/11/22 with chief complaint of harm to others, agitation, refusing medications, MDD (Major depressive disorder, and dementia without behaviors. His admitting diagnosis was unspecified psychosis not due to a substance or known physiological condition. Further review of the medical record showed Staff E, Psychiatric Mental Health Nurse Practitioner - Board Certified (PMHNP-BC) conducted the Initial Psychiatric Evaluation on 05/12/22. There was no evidence that the initial psychiatric evaluation was reviewed, conducted, and/or signed by the psychiatrist.


Patient 4

Review of Patient 4's medical record showed an admission date of 06/03/22 at 12:31 PM with diagnoses unspecified dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) with behavioral disturbances. Further review of the medical record showed the Staff O, APRN conducted the initial psychiatric evaluation for Patient 4 on 06/04/22 at 12:00 AM, and not signed until 06/06/22 at 3:32 PM. There was no evidence that the initial psychiatric evaluation was reviewed, conducted, and/or signed by the psychiatrist.


Patient 6

Review of Patient 6's medical record showed an admission date of 07/31/22 with an admission diagnosis of Bipolar affective disorder (a mental condition marked by alternating periods of elation and depression), current episode manic (extremely elevated and excitable mood). Further review of the medical record showed Staff E, PMHNP-BC, conducted the Initial Psychiatric Evaluation on 08/02/22. There was no evidence that the initial psychiatric evaluation was reviewed, conducted, and/or signed by the psychiatrist.


Patient 7

Review of Patient 7's medical record showed an admission date of 07/28/22 with a diagnosis of Bipolar II Disorder (a mental condition marked by alternating periods of elation and depression). Further review of the medical record showed Staff E, PMHNP-BC conducted the Initial Psychiatric Evaluation on 07/29/22. There was no evidence that the initial psychiatric evaluation was reviewed, conducted, and/or signed by a physician.


Patient 9

Review of Patient 9's current medical record showed an admission date of 07/25/22 with a chief complaint of agitation, physical aggression, refusing medication, refusing cares, anxiety, S/I, and dementia. Further review of the medical record showed Staff E, Psychiatric Mental Health Nurse Practitioner (PMHNP) conducted the Initial Psychiatric Evaluation on 07/26/22. There was no evidence that the initial psychiatric evaluation was reviewed, conducted, and/or signed by the psychiatrist.


Patient 10

Review of Patient 10's medical record showed an admission date of 07/07/22 with a diagnosis of unspecified psychosis (a disconnection from reality) not due to a substance or known physiological condition. Further review of the medical record showed Staff E, PMHNP-BC conducted the Initial Psychiatric Evaluation on 07/08/22. There was no evidence that the initial psychiatric evaluation was reviewed, conducted, and/or signed by the psychiatrist.


During an interview on 08/10/22 at 10:48 AM with Staff E, PMHNP-BC stated that she does complete the Initial Psychiatric Evaluations. She stated that Staff D, Psychiatrist does look over them but does not sign off on them. In a subsequent interview on 08/15/22 at 1:35 PM, Staff E stated that she began completing the Initial Psychiatric Evaluations "maybe end of April/early May."

During an interview on 08/15/22 at 9:57 AM, Staff D, Psychiatrist stated that the hospital has two Psychiatric Nurse Practitioners (NP) and they divide the patients among themselves to complete the Initial Psychiatric Evaluations. According to Staff D, Psychiatrist, she was completing the psychiatric evaluations before the NP's began completing them. When questioned about when this changed, Staff D, Psychiatrist stated that it was this August or July. According to Staff D, Psychiatrist, her understanding is that a Nurse Practitioner is on their own and doesn't need the physician to cosign. When further asked when the NP's started completing the Initial Psychiatric Evaluations, she stated, "maybe the last week of July" and that "I went to a more Supervisor role."