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Based on observation, interviews and record reviews the facility failed to ensure a safe patient care environment was provided as evidenced by the failure to initiate and maintain patient fall prevention measures in 6 out of 11 patient fall events reviewed (Patients #2, #7, A, B, D and E).

The failure created the potential for patients to incur physical injury through falls without preventative measures being in place.

FINDINGS

POLICY

According to the policy Fall Prevention Program, the facility will educate patients and staff on identifying the patient's risk for falling, fall prevention measures and ensure correct interventions are included in the patient's plan of care. Patient's are evaluated for their likelihood to fall on admission, during weekly review and after a fall has occurred.

Evaluation of fall risk is based upon the Morse Fall Scale (MFS) tool which applies a numerical score that correlates to the Fall Protection Classification System. According to the facility Fall Precaution Classification System, an MFS score of 45 or greater requires a red leaf be placed outside the patient's room, above the bed and in the bathroom; patient's will have bed and chair alarms in place when ordered by the physician; and no red leaf patient will be left alone in the bathroom and assistance should be provided for all transfers. Standard fall precautions will be in place.

Additionally, post-fall assessments will be conducted and documented in the patient's medical record.

According to the document Fall Precaution Interventions, standard fall precautions include: a gait belt will be accessible in all patient rooms for staff and patient use, wheels of wheelchairs and beds will be locked, staff are to ensure the nurse call system, telephone and personal items are within reach of the patient.

1. The facility failed to ensure red leaf precautions were maintained for patients with a MFS score of 45 and greater to ensure patient safety.

a) A review of the List of Event Reports revealed 45 fall events occurred during the 4 month period between 11/01/15 and 02/29/16.

On 01/17/16 Patient #2 fell during a transfer in the bathroom with a staff member present. Documentation on the Fall Event Report revealed though the staff member was present the patient was transferring out of the bathroom without assistance. Patient #2's MFS score was 70 which meant s/he should have been assisted during the transfer from the toilet and out of the bathroom. As a result of the fall Patient #2 incurred injuries to his/her skull, spine and a left wrist fracture which required transfer to an outside facility.

Patient E experienced a fall while transferring independently from the toilet to the wheelchair on 02/21/16 at approximately 6:10 a.m. Documentation on the Fall Event Report showed his/her MFS score was 45, which required the presence of staff inside the bathroom to assist the patient with the transfer. Additional review of the report form revealed 2 staff members were standing outside the patient's room waiting for the patient to finish in the bathroom. Patient E was found on the floor of the bathroom in a confused state. Patient E was transported to an outside emergency room to evaluate the new onset of confusion.

Patient D was admitted to the facility on 02/23/16. During the admission process Patient D was left sitting in a wheelchair with his/her personal belongings bag out of reach. Review of the Fall Event Report revealed the patient was reaching for the personal belongings bag when s/he fell from the chair. Patient D experienced a second fall the following day, 02/24/16, while sitting on the edge of the bed as s/he attempted to stand to reach a ringing phone and fell to the floor. According to the Fall Event Report, Patient D had a Morse Fall Score (MFS) of 85, which meant the patient should have been assisted at all times when moving around the facility and had his/her belongings within reach.

On 01/19/16 Patient B had a MFS score of 85 which meant the patients personal items, call device and phone should be within their reach when left alone in the room. Patient B was sitting in a wheelchair in his/her room when the wheelchair fell from under the patient as s/he reached for a phone. Documentation on the Fall Event Report stated the patient's call light and personal items were within reach of the patient which was in contrast to the patient's statement that s/he had to reach for the phone as recorded on the Fall Event Report.

According to a Fall Event Report, dated 01/28/16, Patient A was found on the floor of his/her room when a staff member responded to a call light. The Fall Event report noted Patient A had a MFS of 85, which required the assistance of staff during all transfers out of bed and in the bathroom. According to the Fall Event Report, Patient A attempted to get out of bed to walk to the bathroom when s/he became dizzy and fell to the ground. The Fall Event Report noted the patient had a history of falls.

According to a Fall Event Report, on 02/20/16 during a transfer from the toilet back to the wheelchair, Patient #7 became weak and unable to complete the transfer independently. A staff member assisted the patient to the floor. There was no post-fall assessment completed by the registered nurse (RN) as required by facility policy. According to the the nursing note, dated 02/16/16, Patient #7 required maximum staff assistance for toilet transfers.

On 03/02/16, at approximately 1:30 p.m., observation showed Patient #7 had a red leaf on his/her room door. Patient #7 was assisted by a RN to a wheelchair then independently rolled into the bathroom. Patient #7 was in the bathroom alone with the RN standing outside the closed bathroom door. According to the policy, patients on red leaf status were never to be left alone in the bathroom.

b) on 03/01/16 at 3:00 p.m. an interview was conducted with Physical Therapist (PT) #14. PT #14 stated the red leaf was to show a patient needed staff assistance for transfers, with ambulation and while in the bathroom at all times. PT#14 stated a newly admitted patient was required to be placed on red leaf fall precautions until evaluated by physical therapy for their ability to perform independent transfers and ambulation. Further, PT #14 stated a patient could be approved to perform transfers and ambulation independently only by the physical therapist and this was communicated to the nurse on the communication board in each patient's room, as well as during patient care team conference.

c) On 03/01/16 at 11:43 a.m. an interview was conducted with Rehab Nursing Tech (RNT) #11. RNT #11 stated all patients with a red leaf were required to have a staff member present any time the patient was mobile, including in the bathroom where most falls happened.

d) An interview was conducted with Registered Nurse (RN) #12 on 03/01/16 at 12:06 p.m. RN #12 stated a RN and RNT were assigned to the daily Fall Team and were responsible to respond to any fall incidents to assess the patient, investigate the fall event and make necessary changes to the patient's environment to prevent further falls. RN #12 stated all newly admitted patients were automatically placed on red leaf fall prevention status and any red leaf patient must be assisted by a clinical staff member during transfers, while ambulating, and in the bathroom.

e) On 03/02/16 at 11:16 a.m., a review of patient fall events was conducted with the Chief Nursing Officer (CNO #4) and the Director of Therapy (Director #2). CNO #4 and Director #2 were members of the Fall Team Committee involved in the review of fall events.

CNO #4 stated upon admission, all patients were considered red leaf until evaluated by physical therapy the following day. CNO #4 stated red leaf patients had a MFS of 45 or greater and were to be supervised during all transfers and while in the bathroom. According to CNO #4, all patients with a red leaf were not required to have a bed/chair alarm if they could be trusted to call for assistance. CNO #4 stated after a fall event the patient must have a post-fall assessment documented within their medical record. CNO #4 confirmed there was no post-fall assessment documented for Patient #7 on 02/20/16, as required by policy, to ensure no injury had occurred and to show if any new fall precautions were instituted as a result of the fall.

Director #2 stated although there was no requirement for a red leaf patient to have a bed/chair alarm on, the nurse was able to independently turn the built in bed alarm on or place a chair alarm on the patient then request an order from the physician if the nurse believed the patient would not adhere to the use of the call system to request assistance. S/he further stated the MFS score was inherently subjective to the interpretation of the RN who performed the assessment. This contradicted PT #14's statement that a physical therapy performed the evaluation to determine the patient's need for assistance when transferring, ambulating or in the bathroom.

Director #2 stated falls with serious injury were reviewed by the Fall Team Committee to evaluate trends of falls. Director #2 stated there was no Fall Team Committee meeting in January and February, 2016 because access to fall event data was limited to the Director of Quality/Risk and the position was presently vacant.

Based on observations, interviews, and document review the facility failed to ensure nursing care was provided in accordance with acceptable standards of practice during medication administration and wound care.

This failure created the potential for patients to contract a healthcare acquired infection secondary to improper hand hygiene while handling and administrating medications and performing wound care.

FINDINGS:

POLICY

The policy, Hand Hygiene, stated a hospital wide hand hygiene program protects the patients and personnel from harmful micro-organisms and complies with current Center for Disease Control (CDC) guidelines to prevent the spread of healthcare associated (HAIs) infections.

Hand hygiene shall be performed before and after each direct contact with patients or patient care items. Gloves will not be used as a substitute for hand hygiene and do not negate the need for hand washing. Hand hygiene will be achieved through the use of soap and water or alcohol based sanitizer. Hand hygiene will be performed when moving from a contaminated body site to a clean body site.

REFERENCE

According to the CDC Guideline for Hand Hygiene in Health-Care Settings (MMWR 2002, Vol. 51, No. RR-16) the guideline was provided to health care workers (HCWs) to promote improved hand-hygiene practices and reduce transmission of pathogenic organisms to patients and personnel. Transmission of HAIs from one patient to another occurs via the hands of HCWs through inadequate or omission of hand washing or hand antisepsis between direct patient contacts.

Further, wearing gloves was revealed to prevent hand contamination in conjunction with hand washing. Gloves alone did provide complete protection against hand contamination. Hands should be washed or decontaminated after removing gloves. Failure to remove gloves and perform hand hygiene between patients and/or after dirty procedures may contribute to transmission of organisms.

1. The facility failed to provide safe handling of medications to ensure protection against healthcare acquired infections.

a) On 02/29/16 at 4:05 p.m. Registered Nurse (RN) #18 was observed performing medication administration. RN #18 entered the patient's room, conducted identification verification by handling the patient's wrist band, administered the medication and upon leaving the room did not perform hand hygiene. The lack of hand hygiene was in contrast to the requirements of the Hand Hygiene policy and CDC guidelines.

b) RN #17 performed medication administration on 02/29/16 at 4:16 p.m. RN #17 entered the patient's room, performed identification verification by checking the patient's arm band then administered the medication. No hand hygiene was observed upon entering the patient's room, directly prior to physical contact with the patient or upon exiting the patient's room.

c) On 03/01/16 at 12:04 p.m. an interview was conducted with RN #12 who stated hand hygiene should be performed upon entering and exiting a patient room, before and after direct contact with a patient, and with glove changes.

2. The facility failed to ensure hand hygiene was performed as required during patient wound care procedures.

a) On 02/29/16 at approximately 4:16 p.m. RN #7 was observed performing wound care. RN #7 entered the patient's room and performed hand hygiene prior to donning gloves. RN #7 removed the soiled and contaminated dressing and removed the dirty gloves. RN #7 donned a new pair of gloves and began to clean and redress the wound. No hand hygiene was conducted between the dirty and clean tasks.

RN #7 was interviewed following the wound care procedure and stated there was no need to perform hand hygiene after the glove change because hand hygiene was performed prior to the wound care procedure.

b) An interview was conducted with the Charge Nurse (RN #9) on 02/29/16 at 4:50 p.m. RN #9 stated hand hygiene was to be performed with every glove change and wearing gloves was not a substitution for hand hygiene. RN #9 further stated hand hygiene and glove change were required when going from a dirty task to a clean task.

c) An interview was conducted with the interim Infection Preventionist (RN #15) on 03/02/16 at 3:39 p.m. RN #15 stated hand hygiene was a problem within the facility and efforts were being made to address the concern. RN #15 stated hand hygiene was to be performed according to CDC guidelines and the Hand Hygiene policy.