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Based on interview, review of documentation in the medical record of a patient (Patient 1) who experienced two preventable falls with injuries that required surgery during the hospitalization, review of policies and procedures, and review of other documentation, it was determined the CAH failed to ensure it maintained an effective organizational structure and governing body that was responsible for developing and implementing policies governing the CAH's total operation; and failed to ensure those policies provided for quality health care in a safe environment.

The findings identified during the survey reflect the CAH's limited capacity to provide safe and appropriate care and services and represent a Condition-level deficiency of CFR 485.627, Condition of Participation: Organizational Structure.

Findings include:

1. Refer to the findings at Tag C241, CFR 485.627(a), regarding lack of governing body responsibility for development and implementation of CAH policies and procedures.

Based on interview, review of documentation in the medical record of a patient (Patient 1) who experienced two preventable falls with injuries that required surgery during the hospitalization, review of policies and procedures, and review of other documentation, it was determined the CAH failed to ensure that the governing body developed and implemented policies governing the CAH's total operation and failed to ensure that those policies were administered so as to provide quality health care in a safe environment in the following areas:
* Patient emergencies were not appropriately managed;
* Safety equipment was not used during patient transfers;
* RN assessments and monitoring related to patient falls and fall risk were not conducted;
* Nursing care plans were not developed to include patient specific fall interventions;
* Post fall assessment forms were not completed; and
* Post fall debriefings were not conducted.

Findings:

1. Refer to the Condition-level deficiency at Tag C270, CFR 485.635, Condition of Participation: Provision of Services that reflects Patient 1 experienced two preventable falls with injuries that required surgery during the hospitalization.

Based on interview, review of documentation in the medical record of a patient (Patient 1) who experienced two preventable falls with injuries that required surgery during the hospitalization, review of policies and procedures, and review of other documentation, it was determined the CAH failed to develop and implement written policies and procedures for the patient care services it provided to ensure the provision of safe and appropriate care in the following areas:
* Patient emergencies were not appropriately managed;
* Safety equipment was not used during patient transfers;
* RN assessments and monitoring related to patient falls and fall risk were not conducted;
* Nursing care plans were not developed to include patient specific fall interventions;
* Post fall assessment forms were not completed; and
* Post fall debriefings were not conducted.

The findings identified during the survey reflect the CAH's limited capacity to provide safe and appropriate care and services and represent a Condition-level deficiency of CFR 485.635, Condition of Participation: Provision of Services.

Findings include:

1. Refer to the findings at Tag C294, CFR 485.635(d)(1), related to lack of development and implementation of CAH policies and procedures regarding provision of nursing services in accordance with patient's needs. Those findings include, but are not limited to:
* A patient sustained an injury after falling in the shower and the CAH failed to ensure the patient was appropriately supervised and assessed, including the patient's ability to navigate a potential trip hazard in the shower.
* The patient sustained another injury after falling during an assisted transfer to a private vehicle. Safety equipment was not used for the transfer and the patient's condition was not appropriately assessed after the fall. The patient was subsequently transported in the private vehicle by a non-CAH individual to the CAH ED. The CAH failed to ensure the patient was appropriately monitored during that time.
* Nursing care plans related to fall risk were not developed and implemented based on assessment of the patient's individualized needs.
* Post fall assessment forms were not completed; and
* Post fall debriefings were not conducted.

2. Refer to the findings at Tag C271, CFR 485.635(a)(1), regarding lack of development and implementation of written CAH patient care policies and procedures.

3. Refer to the findings at Tag C296, CFR 485.635(d)(2), related to lack of development and/or implementation of CAH policies and procedures regarding nursing services, including supervision and evaluation of the nursing care of each patient.

4. Refer to the findings at Tag C298, CFR 485.635(d)(4), related to lack of development and/or implementation of CAH policies and procedures regarding nursing services, including nursing care plans developed and kept current for each patient.

Based on interview, review of documentation in the medical record of a patient (Patient 1) who experienced two preventable falls with injuries that required surgery during the hospitalization, and who underwent surgery for repair of the injuries after both falls, review of policies and procedures, and review of other documentation, it was determined the CAH failed to furnish health care services in accordance with appropriate and fully developed and implemented patient care policies and procedures in the following areas:
* Patient emergencies were not appropriately managed;
* Safety equipment was not used during patient transfers;
* RN assessments and monitoring related to patient falls and fall risk were not conducted;
* Nursing care plans were not developed to include patient specific fall interventions;
* Post fall assessment forms were not completed; and
* Post fall debriefings were not conducted.

Findings include:

1. Refer to the findings at Tag C294, CFR 485.635(d)(1), related to lack of development and implementation of CAH policies and procedures regarding provision of nursing services in accordance with patient's needs.

2. Refer to the findings at Tag C296, CFR 485.635(d)(2), related to lack of development and/or implementation of CAH policies and procedures regarding nursing services, including supervision and evaluation of the nursing care of each patient.

3. Refer to the findings at Tag C298, CFR 485.635(d)(4), related to lack of development and/or implementation of CAH policies and procedures regarding nursing services, including nursing care plans developed and kept current for each patient.

Based on interview, review of documentation in the medical record of a patient (Patient 1) who experienced two preventable falls with injuries that required surgery during the hospitalization, review of policies and procedures, and review of other documentation, it was determined the CAH failed to develop and/or implement appropriate nursing policies and procedures to ensure safe and appropriate care was provided in accordance with patients' needs in the following areas:
* Patient emergencies were not appropriately managed;
* Safety equipment was not used during patient transfers;
* RN assessments and monitoring related to patient falls and fall risk were not conducted;
* Nursing care plans were not developed to include patient specific fall interventions;
* Post fall assessment forms were not completed; and
* Post fall debriefings were not conducted.

Findings include:

1. The medical record of Patient 1 was reviewed. The patient was admitted to the CAH on 11/21/2017 at 0739 with diagnoses including right knee degenerative arthritis, schizophrenia, anxiety, depression and bronchitis.

The patient had a total right knee arthroplasty surgery on 11/21/2017 and was transferred to the inpatient floor on 11/21/2017 thereafter.

* The record reflected the patient was assessed to be at risk for falls and that he/she had impulsive behaviors. Examples include:

The RN Fall/Safety Assessment Forms dated 11/21/2017 at 2130; and 11/22/2017 at 1106 reflected:
"Morse Fall Scale"
"History of Falling...No..."
"Secondary Diagnosis...Yes..."
"Ambulatory Aid...Crutches/cane/walker..."
"Intravenous Therapy/Heparin Lock...Yes..."
"Gait Characteristics...Weak..."
"Mental Status...Oriented to own ability..."
"Morse Fall Score...60"
"Patient Considered High Risk for Fall...Yes, the current medications AND/OR the Morse Fall Score of 45 or greater places the patient at risk for falling."

The PT evaluation dated 11/21/2017 at 1633 reflected "...CGA for sit to stand transfers, Min A with gait with FWW due to mild impulsivity...compromised strength, balance, and fall risk..."

The PT notes dated 11/22/2017 at 1642 reflected "...Pt continues to do well with PT, needs frequent vc's to 'slow down' as pt is anxious and moves impulsively."

The RN flowsheets dated 11/24/2017 at 2119; and 11/25/2017 at 2203 reflected "Barriers to Learning" were "Difficulty concentrating."

The PT evaluation dated 11/25/2017 at 0735 reflected:
"Balance...Standing static/dynamic: Poor. Patient had numerous LOB during static standing with FWW..."
"Current functional mobility...Sit to stand: CGA with FWW...Stand to sit: CGA with FWW to min A for LOB..."
"...Pt presents with decrease in R knee AROM/PROM, strength, impaired gait, poor balance, and poor safety awareness. Patient has significant fall history in last year and demonstrated poor FWW strategies when reaching and taking standing rest breaks requiring more than CGA to create safe environment. Patient would benefit from skilled PT to address safety with transfers, gait, balance, and stairs before discharge."

The RN Fall/Safety Assessment Forms dated 11/24/2017 at 1114; 11/24/2017 at 2118; 11/25/2017 at 0948; and 11/25/2017 at 2203 reflected:
"Morse Fall Scale"
"History of Falling...No..."
"Secondary Diagnosis...Yes..."
"Ambulatory Aid...Crutches/cane/walker..."
"Gait Characteristics...Weak..."
"Mental Status" "Oriented to own ability..."
"Morse Fall Score...40"
"Patient Considered High Risk for Fall...Yes, the current medications AND/OR the Morse Fall Score of 45 or greater places the patient at risk for falling."

* The RN notes dated 11/26/2017 at 0815 reflected "...Pt. up to shower, CNA had left to grab linen for bed states Pt had call light in reach. RT...was in room to check Pt, stated [he/she] heard a loud noise and yell by Pt, immediately...went into bathroom and found Pt lying on the floor, called for help. This nurse ran into room, CNA in bathroom at this time with RT...Pt lying on back with [right] knee bent, [right] knee incision with full dehiscence of incision, able to visualize TKA components and bone, profuse bleeding. Pt stated [he/she] stepped on ledge of shower and slipped off dropping down onto [his/her] knee and then falling back onto [his/her] spine. Denied pain anywhere except R) knee...[Physician] stated Pt will have to go back to OR for revision of R) TKA surgery..."

The RN notes dated 11/26/2017 at 1242 reflected the patient was "...taken to OR and given I&D of R) TKA..."

The record reflected the patient underwent surgery on 11/26/2017 for repair of the right knee injury.

The record reflected the patient continued to be at risk for falls and continued to demonstrate impulsive behaviors after the knee surgery. Examples include:

The RN notes dated 11/29/2017 at 1816 reflected "Pt. still impulsive so bed alarm is on."

The RN notes dated 11/30/2017 at 1901 reflected "...Please have alarms on. Dietary reported to...RN that they saw [patient] 'halfway out' of bed today..."

The RN notes dated 12/03/2017 at 1808 reflected "...Dressing changed...Still impulsive..."

The RN notes dated 12/04/2017 at 0700 reflected "Up with right knee brace using walker and 1-2 person SBA...Remains impulsive and has difficulty concentrating. Bed alarm on for safety and call light in reach..."

The RN flowsheets dated 12/04/2017 at 2100 reflected "Ed-Adhere to Fall Specific Precautions...Needs further teaching; and "Ed-Reduce Distractions With Ambulation...Needs further teaching."

The RN Fall/Safety Assessment Forms dated 12/03/2017 at 0946; 12/04/2017 at 1014; and 12/04/2017 at 2257 reflected:
"Morse Fall Scale"
"History of Falling...Yes..."
"Secondary Diagnosis...Yes..."
"Ambulatory Aid...Crutches/cane/walker..."
"Gait Characteristics...Weak..."
"Mental Status...Overestimates/forgets limitations..."
"Morse Fall Score...80"
"Patient Considered High Risk for Fall...Yes, the current medications AND/OR the Morse Fall Score of 45 or greater places the patient at risk for falling."

The OT notes dated 12/05/2017 at 0745 reflected "...pt. donned pants with [CGA] primarily for impulsivity with pants management...Pt. tolerated well. [He/she] continues to be impulsive..."

The PTA notes dated 12/05/2017 at 0816 reflected "Pt. assisted into gait belt...assisted feet to floor with v.c.s to keep knee straight in brace, sit to stand CGA for safety then ambulated with FWW CGA for safety [and] v.c.s to keep knee straight in brace, sit to stand CGA for safety then ambulated with FWW CGA for safety [and] v.c.s to slow down at times...then seated on shower chair in shower with aide SBA...Pt. left with aide for showering...Pt. is tolerating sit to stand better but due to impulsive nature, does not remember to move slowly with good control of RLE knee extension in brace as advised..."

The RN flowsheets dated 12/05/2017 at 1035 reflected "Barriers to Learning...Difficulty concentrating."

The RN notes recorded by RN 1 dated 12/05/2017 at 1400 reflected "...Pt [discharged] to...Adult Foster care. [Individual] from [Adult Foster Care] here to pick up patient.

* ED encounter documentation recorded by an ED RN dated 12/05/2017 at 1434 was reviewed. The documentation reflected the patient presented to the ED "...with staples to right knee, appears to have about 4 staples that tore out toward distal end of incision, pt with some blood...no active bleeding at this time."

The ED Physician notes transcribed 12/05/2017 at 2143 and electronically signed by the physician on 12/06/2017 at 0801 reflected "This [patient] was being discharged from the hospital today when [he/she] fell while getting into the car. [He/she] had a recent procedure of right knee replacement approximately 2 weeks ago. During the recovery period, following surgery, [he/she] suffered a fall in the shower and subsequent wound dehiscence with rupture of the patellar tendon, on 11/26/2017, I believe, is when surgical repair of the patellar tendon was performed. Postoperatively, [he/she] was doing well and was discharged from the hospital this afternoon, while transferring into [his/her] car, [he/she] completely flexed the right knee and there was a pop. [He/she] was subsequently brought to the Emergency Room for reevaluation of the right knee...This is a reoccurrence of a patellar tendon rupture that occurred less than 10 days ago. [He/she] reinjured the patellar tendon today. [Physician] evaluated the patient and will take [him/her] back to the operating room here this afternoon."

The record reflected the patient underwent surgical repair of the right knee injury on 12/05/2017, and was discharged 6 days later on 12/11/2017.

* The RN notes with an "Entered On" date of 12/14/2017 at 1502 were reviewed. The notes were recorded by RN 1 and reflected the following: "...Pt was discharge (sic) from the Med/Surg floor at 1405. Pt was assisted into a wheelchair and accompanied out to a car by myself, a CNA and [individual] from...adult foster care. Pt was taken out to car where [he/she] was assisted to stand and using a walker moved up to the open front door of the car. While remaining next to pt, I moved the walker out of the way so I could assist pt into car. At that time, the pt attempted to get into the car by [him/herself]. Before I could turn back to help pt, [his/her] Rt leg buckled under [him/her]. I immediately lifted pt up and into front seat of the car and sent the CNA to get help from the ER. Since the pt was already in the car the patient was taken around to the ER entrance where [he/she] was assisted out of the car and onto a gurney by the ER nurses and myself. Pt was then taken into the ER for evaluation and treatment."

Review of an Email from the CNO dated 03/29/2018 at 1459 reflected RN 1's note above dated 12/14/2017 at 1502 was a "late entry" note for 12/05/2017.

2. During an interview with CNA 1 on 03/16/2018 at 0840 the following information was provided related to the 11/26/2017 fall incident involving Patient 1:
* The patient came to the CAH for a knee replacement surgery.
* The patient was "very sporadic with getting up and down" and having a lot of pain after his/her knee surgery. CNA 1 stated "I think there was a 'mental aspect.' [He/she] was somewhat childlike and impatient."
* CNA 1 stated he/she spoke with the patient about having a shower.
* CNA 1 stated that frequently patients were showered down the hall in a larger shower because the shower in patients' bathrooms were small and "the patient has to be able to step over a lip threshold" to get in and out of the shower.
* CNA 1 spoke with the RN about the patient having a shower in his/her bathroom instead of down the hall in the larger shower, and the RN said "If the patient thinks [he/she] can do it and you'll be standing by during the shower," then he/she can be showered in his/her bathroom shower.
* The patient was making improvements but still needed frequent reminders to wait for assistance. CNA 1 stated "[He/she] was someone we had to continually let know to call and make sure [he/she] had assistance."
* CNA 1 assisted the patient into the shower in a seated position on a commode. He/she stated there was a rolling linen cart positioned in front of him/her and he/she had a call light in reach.
* CNA 1 turned the water on and closed the shower curtain.
* CNA 1 told the patient he/she would be making his/her bed and "don't do anything unless you call first."
* CNA 1 stated he/she left the bathroom door open "a few inches" and stepped out of the bathroom into the patient's room.
* CNA 1 stated he/she then left the patient's room, and went across and down the hall about two doors to the linen room. CNA 1 stated nobody was in the bathroom with the patient or in the patient's room when he/she left to get the linen.
* CNA 1 stated as he/she was leaving the linen room, he/she heard a scream coming from the patient's room.
* CNA 1 stated he/she went to the patient's bathroom and "when I saw [the patient], [his/her] feet were toward the shower and [his/her] head was out of the shower."
* CNA 1 stated the patient's knee incision "was open and there was a puddle of blood."
* CNA 1 stated the patient said he/she "put [his/her] foot out of the shower and slipped."
* CNA 1 acknowledged he/she left the patient alone in the shower and the patient fell and injured his/her knee.

3. During an interview with RN 1 on 03/16/2018 at 1145 the following information was provided related to the 12/05/2017 fall involving Patient 1:
* RN 1 was the patient's assigned nurse on 12/05/2017. The patient was planned to be discharged on that day.
* RN 1 stated the patient had "very limited weight bearing on the right leg" because he/she had already fallen once before and this was his/her second surgery. He/she stated "[Patient 1] was always trying to get out of bed. [He/she] was very impulsive at the time of discharge." In regards to the patient's safety awareness, RN 1 stated "It was hard to say."
* RN 1 reviewed discharge instructions with the patient in preparation for discharge.
* RN 1 stated "I went over how I wanted [him/her] to get into the car."
* RN 1 stated there was no discussion with the patient about using a gait belt. He/she stated "Not that I can remember."
* RN 1 assisted the patient who was in a wheelchair to a private vehicle (car) in front of the CAH main entrance. A CNA and an individual from the "assisted living" where the patient was discharging to were also present.
* RN 1 described the car as a "four door sedan, fairly low to the ground" with seats that were lower than the wheelchair seat.
* RN 1 stated "We got to the car, I opened the door, put the walker in front of [Patient 1], [he/she] stood up with the walker and moved toward the door, and I moved the walker to the side so I could help [him/her] pivot."
* RN 1 stated his/her left hand was on the patient's side while he/she used his/her other hand to move the walker. RN 1 stated while he/she was moving the walker, the patient lifted his/her left leg to get into the car and his/her "right leg buckled and [he/she] sat on the ground outside the car."
* RN 1 stated "I immediately picked [Patient 1] up and set [him/her] in the front seat of the car. I saw blood coming out of [his/her] sweat pants. I heard a loud pop when [he/she] went down."
* RN 1 stated he/she put pressure on the patient's right knee after lifting him/her up into the car.
* RN 1 stated he/she decided since the patient was already in the car, and the individual from the "assisted living" said he/she would drive the patient around to the ED, he/she would let the individual do it.
* RN 1 stated the individual from the "assisted living" drove the patient in the car to the CAH ED entrance. RN 1 stated nobody from the CAH accompanied the patient.
* RN 1 stated he/she left Patient 1 alone with the individual from the "assisted living" while the individual drove the patient to the ED.
* RN 1 stated "We have a rapid response team for emergencies but it was faster to just drive [Patient 1] around to the ED.
* RN 1 stated he/she did not use a gait belt for the transfer and nobody else assisted with the transfer. RN 1 stated he/she normally used a gait belt for patient transfers, "but not during car transfers." RN 1 stated the "[patient] was partial weight bearing. [He/she] was being cooperative. I was not going to use a gait belt in the parking lot." He/she stated "In [Patient 1's] case, maybe I should have."

4. A policy and procedure titled "Patient Fall Prevention" dated as approved 03/20/2017 reflected the following:
* "All patients will be assessed for fall risk...Appropriate precautions will be implemented in response to the assessed risk...Adults...will be assessed using the Morse Fall Risk Assessment Scale...Interventions will be based on the risk level and clinical judgment. Fall Risk Scores do not supersede individual clinical judgment in the implementation of interventions. Risk scores are a minimum guideline and increasing fall risk level is acceptable..."
* "Post fall guidelines...Before moving the patient...perform a primary and secondary assessment on the patient before lifting the patient from the floor...Once post fall primary and secondary assessments have been completed, follow the...safe patient lifting policy to lift patient from the floor...After all falls Perform and document a head-to-toe assessment...Document in the EMR...Complete the post-fall assessment form...Complete the 24 hour post-fall assessment form...Conduct a post-fall debriefing...Return the post fall Debrief to the manager so further learning's can be communicated...Implement changes to fall prevention plan and document in the medical record and plan of care as appropriate."

* RN Fall/Safety Assessment Form/Morse Fall Scales in Patient 1's medical record reflected the patient had a "Secondary Diagnosis." However, there was no further information or nursing assessment reflecting what that diagnosis was with respect to the patient's risk for falls.

* Patient 1's medical record contained no documentation reflecting a post fall assessment form and 24 hour post fall assessment form were completed after the fall on 12/05/2017; and no documentation reflecting a fall debrief was conducted after the falls on 11/26/2017 and 12/05/2017 in accordance with CAH policy and procedure.

* During an interview on 03/16/2017 at 0825 the CNO stated there were no post fall debrief forms for the falls that occurred on 11/26/2017 and 12/05/2017. The CNO stated "That was not done."

* During an interview on 03/16/2017 at 1230, RN 3 stated the post fall assessment form and 24 hour post fall assessment form were not completed after the patient fell on 12/05/2017.

5. A policy and procedure titled "Lifting & Safe Patient Movement" dated as approved 06/28/2016 reflected "...Patient Assessment...Upon admission and on an ongoing basis, the nursing and/or rehab staff will assess patients' mobility needs. They will determine the level of assistance and equipment needed for patient lifting, and movement skills. Areas to be assessed include cognition, physical abilities...A falling patient is to be assisted to the floor, made comfortable, and instructed to remain on the floor until lift devices are brought to the scene to lift patient from the floor. Under no circumstances should staff lift a falling patient into bed or into a chair. A medical emergency requires additional assessment to determine how best to assist the patient.

Appendix A reflected "This appendix provides assessment criteria to assist health care in the planning for safe handling and movement of each patient...The following algorithms should be used as guides when planning...patient transfers or repositioning tasks. These algorithms are targeted for persons directly involved with patient handling and movement, such as registered nurses...The algorithms are designed to assist health care employees in selecting the safest equipment and techniques based on specific patient characteristics...After a nurse has assessed the patient, three questions should be answered to ensure nurse and patient safety...Which task or tasks does the patient need either partial or full assistance to perform?..What type of equipment or assistive device is needed to perform each task safely?..How many caregivers are needed to complete each task safely?"

An algorithm on Page 9 of the policy titled "Transfer to and from...Car and Chair" reflected:
"Can patient bear weight?" This was followed by two options: "Fully" and "Partially."
After "Partially" it reflected "Is the patient cooperative?" followed by "Yes" and "No".
The instructions following a "Yes" response reflected "Stand and pivot techniques using a gait belt (1 caregiver) or powered standing assist lift (1 caregiver); and the instructions for a "No" response reflected "Use full-body sling lift and 2 caregivers."

* Patient 1's medical record contained no documentation reflecting the RN assessed the patient after the patient fell on 12/05/2017, including before he/she lifted the patient into the private vehicle. There was no documentation reflecting the RN used a gait belt or other safety equipment, or that he/she assessed the patient for equipment or assistive device needs. There was no documentation reflecting the RN or any other CAH staff monitored the patient while the patient was transported to the ED in the vehicle after falling and showing signs of injury. This was confirmed during the interview with RN 1 on 03/16/2018 at 1145 in finding 3.

6. A policy and procedure titled "Rapid Response Team (RRT)" dated as approved 06/28/2016 was provided and reflected the following: "Saint Alphonsus Medical Center-Baker City recognizes and responds to changes in a patients' condition by calling the rapid response team (RRT)...The Rapid Response Team shall respond to all patient care areas...The RRT may be requested when sudden, acute changes are noted, such as, but not limited to...Change in level of consciousness...Significant bleeding...Staff or patient family member worried/concerned about patients declining condition..."

* The policy did not include information about responding to patient emergencies in all CAH areas, including outdoor areas and other areas not specifically designated as "patient care areas."

* During an interview with the CNO and Quality/Risk Manager on 03/16/2018 at 1300, the policy and procedure "Rapid Response Team (RRT)" above was reviewed. The Quality/Risk Manager stated "We don't have a policy that addresses injuries that happen in the CAH parking lot. In my mind this [RRT policy] is for inpatient units." No further policies, procedures or other information were provided related to management of patient emergencies.

7. A policy and procedure titled "Interdisciplinary Plan of Care" dated as approved 10/05/2016 reflected the following: "Patients received care and treatment based on an assessment of the patient's individualized needs. The data obtained from the assessment is used to determine and prioritize the patient's plan for care...Interventions are the plan for achieving the goal or outcome...Interventions can be modified to be more specific to the patient's plan...Additional interventions can be added any time...Documenting in the Plan...Evaluation of the IPOC should be completed at least daily and as appropriate by the RN. Evaluation should include documentation of progression within the plan...Additional justification can be added to the documentation to outline details about the patient's progress."

* Review of the Interdisciplinary Care Plan for Patient 1 reflected it did not include interventions based on an assessment of the patient's individualized needs during shower activities, including the patient's ability to navigate a "ledge" in the shower; and car transfers, including use of gait belt or other equipment with respect to his/her diagnoses of schizophrenia and anxiety, and impulsive behaviors.

* During an interview on 03/15/2018 at 1600 the CNO and RN 2 stated they were not able to find an assessment of the patient's assistance and supervision needs during shower activities. RN 2 stated "I don't know where that would be."

* During interview on 03/16/2018 at 1040 the CNO stated there was no care plan addressing the patient's assistance and supervision needs during showers. He/she stated "The care plan does not specifically call that out." and "We don't have that level of detail."

* During an interview on 03/16/2018 at 1140 with the CNO and RN 3 they confirmed the medical record contained no assessment and no care plan addressing the patient's ability to participate in car transfers including consideration of using a gait belt or other safety equipment.

8. During an interview on 03/15/2017 at 1330 with the CAH President and CNO, they confirmed that the patient fell and sustained knee injuries two times while at the CAH. They also confirmed that the patient required surgery after both falls as a result of the injuries.

* The policy and procedure titled "Patient Rights and Responsibilities" dated as last revised "3/12" reflected "Patients will be offered a copy of their rights..." An undated patient brochure provided to patients to inform them of their patient rights was reviewed. It reflected "Your rights as a Patient...You have the right to safe care..."

Based on interview, review of documentation in the medical record of a patient (Patient 1) who fell two times at the CAH and sustained significant injuries, and who underwent surgery for repair of the injuries after both falls, review of policies and procedures, and review of other documentation, it was determined the CAH failed to ensure a RN supervised and evaluated the patient's nursing care needs in accordance with CAH policies and procedures.

Findings include:

1. Refer to the findings at Tag C294, CFR 485.635(d)(1), related to lack of development and implementation of CAH policies and procedures regarding nursing services, including supervision and evaluation of the nursing care of each patient.

Based on interview, review of documentation in the medical record of a patient (Patient 1) who fell two times at the CAH and sustained significant injuries, and who underwent surgery for repair of the injuries after both falls, review of policies and procedures, and review of other documentation, it was determined the CAH failed to ensure a nursing care plan was developed, implemented and kept current for each patient based on assessment of the patient's individualized needs including fall risk in accordance with CAH policies and procedures.

Findings include:

1. Refer to the findings at Tag C294, CFR 485.635(d)(1), regarding nursing services, including lack of nursing care plans developed and implemented for each patient to include patient specific fall interventions.

Based on interview, review of documentation in the medical record of a patient (Patient 1) who experienced two preventable falls with injuries that required surgery during the hospitalization, review of policies and procedures, and review of other documentation, it was determined the CAH failed to ensure its quality assurance program was effective and prevented patient falls and injuries.

The findings identified during the survey reflect the CAH's limited capacity to provide safe and appropriate care and services and represent a Condition-level deficiency of CFR 485.641. Conditions of Participation for Periodic Evaluation and Quality Assurance Review.

Findings include:

1. Refer to the Condition-level deficiency at Tag C270, CFR 485.635, Condition of Participation: Provision of Services that reflects the CAH quality assurance program was not effective for preventing falls and injuries. Patient 1 experienced two preventable falls with injuries that required surgery.

2. Review of the policy and procedure titled "Quality Improvement and Patient Safety Program" dated as last approved 03/01/2017 reflected "...The Performance Improvement and Patient Safety Program is dedicated, but not limited to, fulfilling the following...Providing a framework for continuously monitoring and improving the safety and the quality of care and service provided to patients...Identifying, designing and implementing new processes to continually improve patient care, safety and service..."