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Based on record review and staff interview, the medical and nursing staff failed to implement an appropriate plan of care for one of one Patient's after a fall with injury in June 2010.

The findings are as follow:

The Patient was readmitted to the Hospital a day following discharge with a intraventricular hemorrhage.

Review of medical record indicated on 06/04/10 at 1:30 AM, the Patient stood and fell to the floor sustaining an acute compression fracture of L1.

Review of the Nursing Assessments between the dates of 06/04/10 to 06/10/10 indicated the Patient remained on bedrest with no specific plan for increasing the Patient's activity without a Thoracic Lumbar Sacral Orthotic (TLSO) backbrace.

Between the dates of 06/04/10 to 06/10/10, the Patient's rehabilitative therapy services were placed on hold for a lack of the TLSO brace.

Registered Nurse #4 said in interview on 07/14/10 at 2:40 PM the nursing staff were to place the order for the TLSO backbrace. Registered Nurse #4 said the TLSO backbrace was to aide in the Patient's pain management.

The Physician's Assistant (PA) was interviewed in person on 07/14/10 at 1:45 PM. The PA did not recall the specifics of the TLSO brace but said the orthotic would require a medical order. The PA informed the Patient's family of the Patient's fall on 06/04/10 at approximately 12 PM.

The Resident Physician was interviewed by telephone on 07/20/10 at 2 PM. The Resident Physician said the Patient was evaluated at the time of the fall and the Patient had difficulty pinpointing the area of pain. The Resident Physician said an x-ray was ordered by not done to late in the morning and the results were not immediately available. The Resident Physician spoke with the family later the same day and they reported the Patient had other falls and we tried to get previous films. The Resident Physician said given the Patient had backpain the compression fracture had to be considered acute. The Resident Physician said an order would not have been necessary for the TLSO orthotic backbrace.

On 06/09/10,an order was written for the TLSO brace to be worn out of bed. The written order was provided to the Surveyor on 07/21/10. On 06/09/10, the Patient was measured for the TLSO back brace by an orthotic vendor.

There was no evidence the Patient's Plan of Care was revised after the Patient fell sustaining a compression fracture to address the Patient's mobility status nor was the Plan of Care updated after the TLSO brace was obtained and provided to the Patient..

On 06/10/10, the Patient was re-evaluated by both the Occupational Therapist and Physical Therapist.

Review of the Physical Therapy Evaluation dated 06/10/10 indicated the Patient was now issued the TLSO and was unsteady with mobility with swaying in all directions.

Based on record review and staff interview, one of one Patient's was not provided care in a safe setting in June 2010.

The findings are as follow:

The Patient was readmitted to the Hospital a day following discharge with a intraventricular hemorrhage.

Review of medical record indicated on 06/04/10 at 1:30 AM, the Patient stood and fell to the floor sustaining an acute compression fracture of L1.

Review of the Nursing Assessments between the dates of 06/04/10 to 06/10/10 indicated the Patient remained on bedrest with no specific plan for increasing the Patient's activity without a Thoracic Lumbar Sacral Orthotic (TLSO) backbrace.

Between the dates of 06/04/10 to 06/10/10, the Patient's rehabilitative therapy services were placed on hold for a lack of the TLSO brace.

Registered Nurse #4 said in interview on 07/14/10 at 2:40 PM the nursing staff were to place the order for the TLSO backbrace. Registered Nurse #4 said the TLSO backbrace was to aide in the Patient's pain management.

The Physician's Assistant (PA) was interviewed in person on 07/14/10 at 1:45 PM. The PA did not recall the specifics of the TLSO brace but said the orthotic would require a medical order. The PA informed the Patient's family of the Patient's fall on 06/04/10 at approximately 12 PM.

The Resident Physician was interviewed by telephone on 07/20/10 at 2 PM. The Resident Physician said the Patient was evaluated at the time of the fall and the Patient had difficulty pinpointing the area of pain. The Resident Physician said an x-ray was ordered by not done to late in the morning and the results were not immediately available. The Resident Physician spoke with the family later the same day and they reported the Patient had other falls and we tried to get previous films. The Resident Physician said given the Patient had backpain the compression fracture had to be considered acute. The Resident Physician said an order would not have been necessary for the TLSO orthotic backbrace.

On 06/09/10,an order was written for the TLSO brace to be worn out of bed. The written order was provided to the Surveyor on 07/21/10. On 06/09/10, the Patient was measured for the TLSO back brace by an orthotic vendor.

There was no evidence the Patient's Plan of Care was revised after the Patient fell sustaining a compression fracture to address the Patient's mobility status nor was there a revision after the TLSO brace had been ordered and obtained for the Patient.

On 06/10/10, the Patient was re-evaluated by both the Occupational Therapist and Physical Therapist.

Review of the Nursing Note dated 06/10/10 at 1:38 PM indicated the TLSO brace on and Patient can get out of bed with PT and OT.

Review of the Nursing Assessment dated 06/11/10 at 6:31 PM indicated the Patient's TLSO brace was on and Patient sat up in bed for one hour for dinner. The Nurses Note indicated the Patient developed a Stage I pressure ulcer behind the left shoulder. The Patient was positioned at 90 degrees.

Continued review of the Nurses Notes dated 06/11/10 at 6:47 AM and 11:38 PM and again on 06/12/10 indicated the TLSO brace was to be on at all times, except when in bed. On 06/12/10, the Nurses Note indicated the TLSO brace was to be worn when the head of the bed was elevated and/or when out of bed.

The Nursing staff did not consistently follow the order for the application of the TLSO brace for the Patient after issued on 06/10/10 and develop and implement an appropriate Plan of Care.


Refer to A-Tag 0395, A-Tag 0396.

Based on record review and staff interview, the registered nurse failed to ensure one of one Patient's had been clearly identified as at risk for a fall after transfer to the inpatient unit in June 2010.

The findings are as follow:

The Patient was readmitted to the Hospital the day following discharge with a intraventricular hemorrhage and status-post VP shunt placement.

Review of the Admission Nursing Assessment to the inpatient unit dated 06/03/10 at 3 PM indicated the Patient had been transferred from the Intensive Care Unit. The Nursing Assessment indicated the Patient was not able to respond to any questions and was disoriented to time and place. The Nursing Assessment indicated the Patient had strong upper extremity strength and weak lower extremity strength. The Patient required assistance of two for mobility secondary to an unsteady gait. The Patient's Morse Fall Risk Score was rated with a score of 30 which placed the Patient at low risk for falls.

The Patient's Morse Fall Risk Score inappropriately identified the Patient as a low risk for falls and contradicted the nursing assessment.

On 06/03/10 at 4 PM, the Occupational Therapist (OT) evaluated the Patient. The OT indicated the Patient had poor safety awareness. The OT indicated the Patient had minimal to moderate ability to transfer from a sitting to standing position and easily distracted. The OT activated the Patient's bed alarm.

Registered Nurse #2 was interviewed by telephone 07/14/10 at 5 PM. Registered Nurse #2 said and documented on 06/03/10 at 5:30 PM, the Patient Care Technician assisted the Patient to the bathroom and the Patient's gait was unsteady with one assist. Registered Nurse #2 said the Patient Care Technician was instructed to then offer the bedpan and not toilet the Patient. Registered Nurse #2 then transferred the care of the Patient to Registered Nurse #3.

Registered Nurse #3 documented on 06/03/10 at 10 PM, the Patient required assistance of two persons for toileting. The Nursing Assessment indicated the Patient had limited attention and was disoriented to time and place. Registered Nurse #3 evaluated the Patient's Morse Fall Risk Score as 50, still placing the Patient at low risk for falls. There was no documentation the bed alarm had been activated by Registered Nurse #3.

Registered Nurse #3 was interviewed by telephone on 07/20/10 at 11 AM. Registered Nurse #3 said the Patient was in and out of confusion and she activated the bed alarm. Registered Nurse #3 said someone had toileted the Patient with the assistance of one and did not reactivate the bed alarm. Registered Nurse #3 was unable to identify the staff person. Registered Nurse #3 said on return to the Patient's room for a safety check, the Patient was standing at the bedside and then fell to the floor. Registered Nurse #3 witnessed the Patient's fall but was unable to reach the Patient. Registered Nurse #3 did not recall the time of the fall but later filed an incident report. Registered Nurse #3 said the Patient was taken for an x-ray but a call was never made to the unit of the results. Registered Nurse #3 said after the fall the Patient remained on bedrest.

There were inconsistencies in the nursing interventions for the Patient's safety and fall risk. There was no documentation for the Patient's safety and risk for falls as clearly outlined in the OT Evaluation.

Review of the nursing documentation between the dates of 06/04/10 to 06/10/10 indicated the Patient was to remain on bedrest and rehabilitation therapy service held until the thoracic lumbar sacral orthotic (TLSO) was obtained.

Review of the Nurses Note dated 06/06/10 at 11 PM indicated the Patient could get out of bed tomorrow with the TLSO brace.

There was no specific plan developed and/or revised for the Patient's mobility status between the dates of 06/04/10 to 06/10/10.

On 06/09/10, the TLSO brace was ordered by a physician's assistant. The written order was provided to the Surveyor on 07/21/10 and not during the initial survey date. The order indicated the TLSO brace was to be worn when out of bed.

Review of the Nursing Note dated 06/10/10 at 1:38 PM indicated the TLSO brace on and Patient can get out of bed with PT and OT.

Review of the Nursing Assessment dated 06/11/10 at 6:31 PM indicated the Patient's TLSO brace was on and Patient sat up in bed for one hour for dinner. The Nurses Note indicated the Patient developed a Stage I pressure ulcer behind the left shoulder. The Patient was positioned at 90 degrees.

Continued review of the Nurses Notes dated 06/11/10 at 6:47 AM and 11:38 PM and again on 06/12/10 indicated the TLSO brace was to be on at all times, except when in bed. On 06/12/10, the Nurses Note indicated the TLSO brace was to be worn when the head of the bed was elevated and/or when out of bed.

The Nursing staff did not consistenly follow the order for the application of the TLSO brace for the Patient after issued on 06/10/10 and develop and implement an appropriate Plan of Care.

Refer to A-Tag 0396.

Based on record review and staff interview, the nursing staff failed to develop and implement an appropriate Plan of Care for two of three Patient's (A and B) at risk for a fall.

The findings are as follow:

PATIENT A:

Patient A was readmitted to the Hospital the day following discharge with a intraventricular hemorrhage and status-post VP shunt placement.

Review of the Admission Nursing Assessment to the inpatient unit dated 06/03/10 at 3 PM indicated Patient A had been transferred from the Intensive Care Unit. The Nursing Assessment indicated Patient A was not able to respond to any questions and was disoriented to time and place. The Nursing Assessment indicated Patient A had strong upper extremity strength and weak lower extremity strength. Patient A required assistance of two for mobility secondary to an unsteady gait. Patient A's Morse Fall Risk Score was rated with a score of 30 which placed the Patient at low risk for falls.

Patient At's Morse Fall Risk Score inappropriately identified the Patient as a low risk for falls and contradicted the nursing assessment.

On 06/03/10 at 4 PM, the Occupational Therapist (OT) evaluated Patient A. The OT indicated Patient A had poor safety awareness. The OT indicated Patient A had minimal to moderate ability to transfer from a sitting to standing position and easily distracted. The OT activated Patient A's bed alarm.

Registered Nurse #2 was interviewed by telephone 07/14/10 at 5 PM. Registered Nurse #2 said and documented on 06/03/10 at 5:30 PM, the Patient Care Technician assisted Patient A to the bathroom and Patient A's gait was unsteady with one assist. Registered Nurse #2 said the Patient Care Technician was instructed to then offer the bedpan and not toilet Patient A. Registered Nurse #2 then transferred the care of Patient A to Registered Nurse #3.

Registered Nurse #3 documented on 06/03/10 at 10 PM, Patient A required assistance of two persons for toileting. The Nursing Assessment indicated Patient A had limited attention and was disoriented to time and place. Registered Nurse #3 evaluated Patient At's Morse Fall Risk Score as 50, still placing Patient A at low risk for falls. There was no documentation the bed alarm had been activated by Registered Nurse #3.

Registered Nurse #3 was interviewed by telephone on 07/20/10 at 11 AM. Registered Nurse #3 said Patient A was in and out of confusion and she activated the bed alarm. Registered Nurse #3 said someone had toileted the Patient with the assistance of one and did not reactivate the bed alarm. Registered Nurse #3 was unable to identify the staff person. Registered Nurse #3 said on return to the Patient A's room for a safety check, Patient A was standing at the bedside and then fell to the floor. Registered Nurse #3 witnessed the Patient A's fall but was unable to reach Patient A. Registered Nurse #3 did not recall the time of the fall but later filed an incident report. Registered Nurse #3 said Patient A was taken for an x-ray but a call was never made to the unit of the results. Registered Nurse #3 said after the fall Patient A remained on bedrest.

There were inconsistencies in the nursing interventions for Patient A's safety and fall risk. There was no documentation for Patient A's safety and risk for falls as clearly outlined by the OT.

Review of the nursing documentation between the dates of 06/04/10 to 06/10/10 indicated Patient A was to remain on bedrest and rehabilitation therapy service held until the thoracic lumbar sacral orthotic (TLSO) was obtained.

Review of the Nurses Note dated 06/06/10 at 11 PM indicated Patient A could get out of bed tomorrow with the TLSO brace. There was no brace made available to Patient A until 06/10/10.

On 06/09/10, the TLSO brace was ordered by a physician's assistant. The written order was provided to the Surveyor on 07/21/10 and not during the initial survey date. The order indicated the TLSO brace was to be worn by Patient A when out of bed.

Review of the Nursing Note dated 06/10/10 at 1:38 PM indicated the TLSO brace on and Patient A can get out of bed with PT and OT.

Review of the Nursing Assessment dated 06/11/10 at 6:31 PM indicated the Patient's TLSO brace was on and Patient A sat up in bed for one hour for dinner. The Nurses Note indicated the Patient A developed a Stage I pressure ulcer behind the left shoulder. The Patient A was positioned at 90 degrees.

Continued review of the Nurses Notes dated 06/11/10 at 6:47 AM and 11:38 PM and again on 06/12/10 indicated Patient A's TLSO brace was to be on at all times, except when in bed. On 06/12/10, the Nurses Note indicated the TLSO brace was to be worn when the head of the bed was elevated and/or when out of bed.

There was no specific plan developed and/or revised for Patient A's mobility status between the dates of 06/04/10 to 06/10/10.

The Nursing staff did not consistently follow the orders written by the PA after Patient A was issued the TLSO brace on 06/10/10 and develop and implement an appropriate Plan of Care.


PATIENT B:

Patient B was admitted to the Hospital in May 2010 with a complicated medical history including cardiomyopathy, lymphoma, bilateral breast cancer, hypertension, polycystic kidney disease with hemodialysis. Patient B complained of having diarrhea for a period of six days, fatigue, weakness over six months.

Review of the medical history indicated Patient B reported having a fall in 2009. Patient B's initial Morse Fall Score was rated as a 20 which identified Patient B as a low risk for falls.

Review of the Nurses Assessment dated 06/02/10 at 9 PM indicated the Patient's left and right lower extremities were weak and Patient B was unsteady ambulating. Morse Fall Score was rated low at 35. Patient B remained in bed.

Review of the Nursing Assessment dated 06/03/10 at 1:23 PM indicated Patient B's Morse Fall Score was rated low at 45 and the intervention included to stay with Patient B while toileting in the bathroom or on the bedside commode. At 11:12 PM, Patient B's Morse Fall Score decreased to 35.

Review of the 7 PM to 7 AM Shift Note dated 06/03/10 at 5:20 PM indicated the morning laboratory drawn and sent. Patient B was unable to stand for weight due to unsteady gait from fall. Patient B was placed on falls precautions and a bed alarm was issued.

There was no specific time documented for Patient B's fall. It was no specifically clear if the fall occurred on 06/03/10 or 06/04/10.

Review of the Post Fall Assessment Tool for Patient B indicated on 06/04/10 at 2 AM Patient B fell and was found sitting on the floor slumped over the toilet.

Review of the Nursing Assessment dated 06/04/10 at 12 AM indicated the Patient was delirious.

Review of the Nurses Note dated 06/04/10 at 2 AM indicated Patient B rang the call bell system and the Nursing Technician found Patient B on the floor. Patient B denied loosing consciousness and striking the head. Patient B was evaluated by a physician and monitored closely. Patient B complained of hand tingling of hands and feet. Fall precautions were implemented after the fall. Nursing Note indicated there was no need for a head computerized tomography (CT).

Review of the Shift Nursing Note dated 06/04/10 at 4:22 AM indicated Patient B hallucinated and examined by a physician. Patient B was found with focal deficits with some left mouth droop and difficulty lifting left arm. Patient B's left arm was placed over head and Patient B could not maintain position. There was no head trauma and the Risk Management Department was notified and Magnetic Renascence Imaging (MRI) done. Family members in with Patient and informed of change in condition.

Patient B was evaluated by the Stroke Team and sustained multiple intracranial hemorrhages.

Review of the Nursing Assessment dated 06/04/10 at 10 AM indicated Patient B fell last night with no injury to the head. Morse Fall Score was rated as a high level for fall with a score of 85. The Patient was drowsy.

Continued review indicated Patient B's Plan of Care had not been updated for the Patient's change in condition and safety precautions needed to maintain Patient B's safety.

Review of the Patient Assessment/Adult Critical Care Plan indicated Patient B had a fall in the bathroom on 06/03/10 and denied hitting the head. The Falls Safety Plan was left blank.

Based on record review and staff interview, one of one Patient medical records lacked sufficient documentation for the management of the Patient after a fall with injury in June 2010.

The findings are as follow:

Review of the medical record indicated on 06/04/10 at 1:30 AM the Patient fell to the floor.

The Resident evaluated the Patient on 06/04/10 at 1:30 AM and documented the Patient tried to get out of bed and the staff were unable to reach the Patient to prevent the fall. The Resident indicated the Patient immediately complained of back and hip pain. The Patient was to be maintained on bedrest. An x-ray of the Lumbar Spine dated 06/04/10 at 2 AM indicated the Patient had a compression fracture of L1 and osteoporosis.

Review of the Medical Progress Note dated 06/04/10 at 6 AM indicated the Patient fell from a standing position. There was no notation of the results of the Lumbar Spine X-ray taken on 06/04/10 done at 1:37 AM and read by the radiologist at 1:47 AM. The Resident Physician recommended the Patient be evaluated by physical and occupational therapy.

The Resident Physician said the results of the x-ray were not known until later the same day.

The Risk Manager said the Patient's x-ray was done on 06/04/10 at 3:10 AM and read by the radiologist at 9:45 AM.

The Occupational Therapist and Physical Therapist documented in a progress note dated 06/04/10 at 3:30 PM the Patient was on flat bedrest per discussion with the registered nurse. The OT and PT indicated the evaluation was on hold for today and will follow-up as medically appropriate.

There was no written Plan of Care for the management of the Patient for mobility and the Patient remained in bed. On 06/10/10 a TLSO backbrace was applied by the PT.

Review of the Physical Therapy Evaluation dated 06/10/10 indicated the Patient was unstable with mobility and swaying in all directions.
Review of the Nursing Note dated 06/10/10 at 1:38 PM indicated the TLSO brace on and Patient A can get out of bed with PT and OT.

Review of the Nursing Assessment dated 06/11/10 at 6:31 PM indicated the Patient's TLSO brace was on and Patient A sat up in bed for one hour for dinner. The Nurses Note indicated the Patient A developed a Stage I pressure ulcer behind the left shoulder. The Patient A was positioned at 90 degrees.

Continued review of the Nurses Notes dated 06/11/10 at 6:47 AM and 11:38 PM and again on 06/12/10 indicated the TLSO brace was to be on at all times, except when in bed. On 06/12/10, the Nurses Note indicated the TLSO brace was to be worn when the head of the bed was elevated and/or when out of bed.

There was no specific plan developed and/or revised for the Patient's mobility status between the dates of 06/04/10 to 06/12/10.

The Nursing staff did not consistently follow the orders written by the PA after the Patient was issued the TLSO brace on 06/10/10 and develop and implement an appropriate Plan of Care.

On 06/12/10, the Patient was discharged to a rehabilitation hospital for further management.

There was no coordination of care between the medical, nursing and rehabilitation disciplines for the management of the Patient after a fall with injury.

Refer to A-Tag 0395 and A-Tag 0396.

Based on record review and staff interview, the medical team, rehabilitation services and the nursing staff failed to coordinate the management of the Patient's compression fracture after a fall with application of a TLSO back brace for one of one Patient's and failed to ensure the appliance was provided to the Patient in a timely manner in June 2010.

The findings are as follow:

Review of the medical record indicated an order for the application of a TLSO backbrace was written on 06/09/10 by a physician assistant and supplied by an orthotic vendor on 06/10/10.

The Nurses Note dated 06/06/10 at 11 PM indicated the Patient could get out of bed tomorrow with the TLSO brace which not made available for an additional four days.

On 06/09/10, a requisition was sent to the orthotic vendor for the Patient to be fitted for the TLSO.

The Patient remained on bedrest for six days without a specific plan for mobility until the TLSO backbrace was delivered on 06/10/10.

There was no documentation by either the medical staff or nursing for the Patient's tolerance of the TLSO after implementation. There was no follow up assessment to the Patient's development of a Stage I pressure sore located behind the Patient's left shoulder.

On 06/12/10, the Patient was transferred to a rehabilitation facility for further medical management.

Refer to A-Tag 0395, A-Tag 0396 and A-Tag 0464.