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Based on interview and record review, facility failed to ensure patient education and communication were provided in a manner that supported informed decision-making for one of 30 sampled patients (Patient 19), when nursing documentation reflected education on safety and fall prevention was provided without evidence of interpreter involvement.

This failure had the potential to result in the patient not being fully informed and or understanding of instructions to make decisions regarding medical care, and to create a distrust toward the healthcare team, which could have contributed to the patient's fall and jeopardized health and safety.

Findings:

During a review of Patient 19's face sheet (contains demographic and medical information), undated, the face sheet indicated, Patient 19 was admitted to the facility on May 14, 2025, with diagnoses which included End-Stage Renal Disease (ESRD- kidneys have stopped working well enough to keep one alive) on peritoneal (belly) dialysis (way to clean out blood when kidneys are not working properly); anemia (body does not have enough healthy red blood cells to carry oxygen to the body); peritoneal dialysis catheter leakage [the fluid that is supposed to stay inside the belly during peritoneal dialysis (PD) starts leaking out through catheter (soft, thin, flexible tube used to put fluids in or take fluids out of the body) site or surrounding tissues (group of cells that team up to do a specific job)].

During a review of Patient 19's "[name] Fall Risk Score," dated May 22, 2025, the record indicated Patient 19 was identified as a "high fall risk" with a score of 16, based on the fall assessment risk (a tool used to determine the patient is at risk for falling; scoring from 7-10 is low risk; scoring 11-14 is moderate risk; scoring above 15 is high risk).

During a review of Patient 19's "Learning Assessment," dated February 1, 2024, (previous admission) reflected Japanese as the preferred language, with interpreter services recommended.

During a review of Patient 19's "Physician Progress Note," dated May 15, 2025, the record indicated, " ...Pt (patient) preferred to use translator app on her phone during discussion ..."

During a review of Patient 19's "Learning Assessment," dated June 6, 2025, indicated the patient's primary/preferred language was Japanese and English, with a recommendation for interpreter services.

A further review of Patient 19's multidisciplinary (different types of specialties working together as a team) notes indicated language barrier and interpreter services were used to provide education and care instructions to the patient as follows:

Physician Progress Note dated May 15, 2025.
Social Worker Note dated May 15, 2025.
Physician Progress Note dated May 18, 2025.
Physical Therapy Note dated May 18, 2025.
Case Manager Note dated May 19, 2025.
Physician Progress Note dated May 19, 2025.
Physical Therapy Note dated May 21, 2025.

A concurrent interview and record review on September 10, 2025, at 8:10 AM, with Patient Safety 2 (PS 2), Patient 19's "Learner Documentation," dated May 17, 2025, to May 22, 2025, was reviewed. The record indicated patient education was provided regarding safety and fall prevention, including call light (device used to call for help) with, "acceptance, explanation, teach back/verbalized understanding," however, there was no documentation that interpreter services were used by nursing staff during patient education specifically about fall prevention interventions. PS 2 confirmed documentation of interpreter and other alternative services, such as reading materials or pictures could be noted in documentation but none were found.

During an interview on September 10, 2025, at 8:20 AM, with Registered Nurse Educator 1 (RNE 1), the RNE 1 stated the use of interpreter services was determined by a "nurse's judgement" rather than consistently based on the learning assessment. RNE 1 further stated, there should be documentation of refusal of interpreter services for every education opportunity if the patient prefers any interpreter usage.

During a concurrent interview and record review during September 10, 2025, at 8:25 AM, with Unit Manager 1 (UM 1), the facility's policy and procedure (P&P) titled, "Communication with patients who have limited English proficiency and/or hearing, speech, or vision impaired," revised February 2025, was reviewed. The P&P indicated, " ...General Principle: ...Healthcare information must be communicated plainly in a language or mode that can be understood by the patient or surrogate decision-maker ...Purpose: ...interpretation is the use of a third party to facilitate accurate communication between two or more individuals ...2.1 ...This offer to the patient and the response shall be documented in the patient's medical record ..." UM 1 stated there was no documentation of the nurses using a translator or offering translation services to Patient 19. UM 1 further stated, it should have been documented per policy.

Based on interview and record review, facility failed to ensure policies and procedures (P&P) were followed for two of 30 sampled patients (Patient 15 and 19) when:

1. For Patient 15, a critical laboratory test result (patient blood work that is far outside normal values it is considered to be life-threatening unless something is done promptly) of potassium (K- an electrolyte essential to the body's function and maintaining a regular heartbeat) for Patient 15 was not reported to patient's physician within 10 minutes as per the facility P&P.

2. For Patient 19, a hospital bed alarm, that was documented to be armed (activated and on), in use for a high risk fall patient and was reported failed to activate during a fall, was not removed from patient care service and evaluated by maintenance service.

These failures resulted in an inadequate nursing process (to gather information, identify patient problems, set goals, carry out interventions, and then evaluate how effective those interventions were in improving the patient's health) and failure of communication between the interdisciplinary team (a group of healthcare professionals who collaborate to achieve patient care goals through joint assessments and interventions) that delayed interventions to promote quality of care and patient safety.

Findings:
1. During a review of Patient 15's "History and Physical"(H&P- a document containing patient story, physical exam and planned treatment) dated August 26, 2025, the "H&P" indicated, Patient 15 was admitted to the facility on August 26, 2025, with diagnoses including ileus (when your intestines temporarily stop working properly, so they can't move food, fluid, and waste through your body) and hydroureteronephrosis (swelling of the upper urinary tract, including the kidney and its drainage tube [ureter], due to a buildup of urine caused by a blockage).

During a review of Patient 15's "Basic Metabolic Panel" (BMP - a blood test that checks on the health of your kidneys, your blood sugar level, and your body's fluid and electrolyte balance) dated August 29, 2025, the "BMP" indicated, Patient 15's potassium (K) was 2.9 [normal refence range 3.5-5.0] and " ...Comment: Critical K result called and read back from [name of nurse]" on August 29, 2025 at 7:13 AM.

During a concurrent interview and record review, on September 10, 2025, at 9:45 AM, with the Manager of Patient Care (MPC), Patient 15's "BMP" dated August 29, 2025, and Patient 15's "Flowsheet" dated August 29, 2025, was reviewed. The "Flowsheet" indicated, the attending physician was notified by nursing, Patient 15's critical potassium at 10:10 AM on August 29, 2025. The MPC stated, the nurse has 10 minutes to notify the attending physician of a critical lab result and then document that interaction and any orders to correct the critical result from the attending physician in the patient's chart. The MPC further stated Patient 15's critical laboratory value of potassium was not communicated to the attending physician in a timely manner and the attending physician should have been notified by 7:23 AM on August 29, 2025.

During a review of the facility's P&P titled, "Reporting of Critical Test Results", dated September 2023, the P&P indicated, " ...B. CRITICAL TEST RESULTS 1. Critical test results shall be called to the patient's licensed caregiver ...The results should be read back to the reporting individual to ensure accuracy and documented in the medical record. 2. All subsequent notifications shall also be read back, e.g., physician reads back test results to nurse who calls him or her. 3. All critical test results shall be reported immediately as is practicable ...Preferred time frames shall be as follows ...3.3 Nursing staff/RCP to physician or other licensed practitioner (when critical values are called to the unit instead of directly to the physician): 10 minutes ...".


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2.During a review of Patient 19's face sheet (contains demographic and medical information), undated, the face sheet indicated, Patient 19 was admitted to the facility on May 14, 2025, with diagnoses which included End-Stage Renal Disease (ESRD- kidneys have stopped working well enough to keep one alive) on peritoneal (belly) dialysis (way to clean out blood when kidneys are not working properly); anemia (body does not have enough healthy red blood cells to carry oxygen to the body); peritoneal dialysis catheter leakage [the fluid that is supposed to stay inside the belly during peritoneal dialysis (PD) starts leaking out through catheter (soft, thin, flexible tube used to put fluids in or take fluids out of the body) site or surrounding tissues (group of cells that team up to do a specific job)].

During a review of Patient 19's medical record, dated May 22, 2025, the "Fall Occurrence" indicated Patient 19 was identified as a "high fall risk" with a score of 16, (a tool used to determine the patient is at risk for falling; scoring from 7-10 is low risk; scoring 11-14 is moderate risk; scoring above 15 is high risk). A further review of the document indicated with the following fall prevention measures: non-skid (not slippery) socks, call light (device used to call for help) in reach, bed locked in lowest position, and bed alarm on.

During a review of Patient 19's "Multidisciplinary Progress Note," dated May 22, 2025, at 1:30 PM, the progress note stated, "Called by staff to pt's [patient] room. Pt seen sitting on the floor. Says she came from the bathroom and forgot to pull the cord and tried to make it back to bed. Says she hit right side of face. [Physician NAME] (MD 1) made aware and ordered stat (as soon as possible) head CT (computed topography - super-powered x-ray that gives doctors detailed pictures of the inside of the body) ...".

A review of the "CT Head WO (without) Contrast," dated May 22, 2025, at 3:44 PM, the result indicated "intracranial (inside the skull) hemorrhage (bleeding)."

During a concurrent interview and record review on September 8, 2025, at 10:34 AM, with Unit Manager 1 (UM 1), Patient 19's "Fall Risk Preventions," dated May 22, 2025, was reviewed. The medical record indicated the bed alarm was armed and in use at the time of the fall. UM 1 stated, staff documented the alarm was on, but the alarm did not sound during the incident. UM 1 further stated staff did not hear the alarm during the incident.

During an interview on September 10, 2025, at 11:14 AM, with Patient Safety 1 (PS 1), PS 1 confirmed there was no work order put in for Patient 19's bed. PS 1 stated, nursing staff inspected the bed post-fall, and the alarm was working then, so staff decided not to place in a work order. However, there was no documentation staff evaluated the patient bed or the bed was removed from patient care.

During a concurrent interview and record review on September 10, 2025, at 12:11 PM, with UM 1, the policy and procedure (P&P) titled, "Medical Equipment Management and Safety," revised April 2024, was reviewed. The P&P indicated, "1. [NAME of the facility] shall provide a Medical Equipment Management Program to ensure that medical equipment is safe and effective for use by patients and staff ...3.6. Ensure that equipment problems, failures, repairs, and operator errors shall be identified and actions of resolution taken and documented ...4.1 Ensure staff is knowledge in the following areas: ...d. Process for reporting equipment defects (e.g., failure, problem, error) ...5. Staff shall be responsible to: 5.1. Use equipment safely, checking it prior to use, and leaving it in good condition after use ...5.4. Identify equipment defects (e.g., failure, problem, error) and taking the following action: ...a. Immediately removing equipment from service if it compromises safety ...c. Notifying service staff in established manner to achieve a timely repair ..." UM 1 stated there was no documentation the bed alarm was removed from service or evaluated by maintenance after the fall event. UM 1 further stated the facility did not follow the P&P.