HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure nursing staff accurately assessed and documented patient condition to support the need for enhanced, continual observation for three of 31 sampled patients (Patients 4, 12, 15) reviewed for sitter (staff member who stays in the patient's room at all times to watch them closely) /tele-sitter (video camera system that allows staff to watch the patient remotely from a central monitoring station) interventions.

This failure had the potential to compromise patient safety by allowing inaccurate assessments to drive care decisions, leading to inappropriate sitter use, delayed interventions, or missed opportunities to prevent patient harm.

Findings:

1. During a review of Patient 4's face sheet (contains demographic and medical information), the face sheet indicated, Patient 4 was admitted to the facility on September 9, 2025, with diagnoses including bilateral knee pain, arthritis (swollen, stiff, painful joints) flare-up (symptoms come back stronger than usual); and difficulty ambulating (walking).

During a review of Patient 4's clinical record, titled "Cognitive/Neuro/Behavioral," dated September 28 and 29, 2025, it indicated Patient 4 was documented as "Glasgow Coma Scale (GCS - score used to measure how awake and responsive someone is; score 3 is no response, 8 or less is severe brain injury, 15 is fully awake and alert) 15, alert and oriented x4 (knows who they are, where they are, what time it is, and what they are there for), and cooperative."

During a concurrent observation and interview on September 29, 2025, at 10:26 AM, with Nurse Manager 3 (NM 3) in Patient 4's room, Patient 4 was observed resting in the bed. A tele-sitter was placed at bedside, plugged in and working. NM 3 stated, "Patient is impulsive and gets out of bed without asking."

During a concurrent interview and record review on September 30, 2025, at 10:16 AM, with Quality Management Staff 2 (QMS 2), Patient 4's clinical record, titled "Safety," dated September 28 and 29, 2025, was reviewed. "Safety," indicated Patient 4 had a tele-sitter at bedside. QMS 2 confirmed there was no clinical justification or behavioral description documented in the record to support the need for a tele-sitter.

2. During a review of Patient 15's face sheet, the face sheet indicated Patient 15 was admitted to the facility on September 28, 2025, with diagnoses including dizziness and fall with head contusion (bruise).

During a review of Patient 15's clinical record, titled "Adult Patient Care Summary (PCS - shows most important information about the patient)," dated September 29, 2025, the PCS indicated Patient 15 was documented as "Within Defined Limits (WDL - every single part of the assessment is normal, and in the expected, healthy range)" under neuro and behavioral assessments.

During a concurrent observation and interview on September 29, 2025, at 10:48 AM, with NM 2 in Patient 15's room, Patient 15 was observed resting in bed with a sitter at bedside. NM 2 stated, "Patient is confused, weak, impulsive and tries to get up out of bed."

A concurrent interview and record review on October 1, 2025, at 9:52 AM, with QMS 2, Patient 15's clinical record, titled "Safety," dated September 29, 2025, was reviewed."Safety" indicated Patient 15 had a sitter at bedside. QMS 2 confirmed there was no other clinical justification or behavioral description documented in the record to support the need for a sitter.

3. During a review of Patient 12's face sheet, the face sheet indicated Patient 12 was admitted to the facility on September 25, 2025, with diagnoses including chest pain and shortness of breath.

During a review of Patient 12's clinical record, titled "Adult Patient Care Summary (PCS) dated September 29, 2025, the PCS indicated Patient 12 was documented as "Within Defined Limits (WDL - every single part of the assessment is normal, and in the expected, healthy range)" under neuro and behavioral assessments.

During a concurrent observation and interview on September 29, 2025, at 1:39 PM, with Nurse Manager 4 (NM 4), in Patient 12's room, Patient 12 was observed in a chair with family members nearby. A sitter was noted at bedside. NM 4 stated, "Patient 12 needs a sitter because Patient 12 has a habit of taking off the high-flow nasal cannula (oxygen therapy that gives a larger amount of warm, moist oxygen through soft tubes in the nose)."

During a concurrent interview and record review on September 30, 2025, at 3:47 PM, with QMS 2, Patient 12's clinical record, titled "Safety," dated September 29, 2025, was reviewed. "Safety" indicated Patient 12 had a sitter at bedside. QMS 2 confirmed there was no other clinical justification or behavioral description documented in the record to support the need for a sitter.

During a concurrent interview and record review on October 1, 2025, at 10:22 AM, with Risk Management Staff (RMS) and QMS 2, facility's policy and procedure (P&P) titled, "Sitter Utilization," revised June 2019, was reviewed. The P&P indicated, " ...Procedure/Guidelines ...A. Assessment: ...1. The clinical appropriateness for a sitter is determined by the physician and/or the nurse, based on assessment or the patient's needs ...3. The following will be considered in assessment of a patient for sitter use: a. Assessment for physiological changes including confusion. b. utilization of least restrictive measures. c. the consideration of safe and appropriate use of restraints. d. consequences/potential outcome of a fall ..." RMS and QMS 2 confirmed accurate clinical assessment was important in order to support the need of a sitter.

During an interview on October 1, 2025, at 10:45 AM, with Certified Nurse Assistant (CNA), CNA stated, "We often sit for patients who are suicidal, at risk for self-harm, and confused patients. There is usually a strong reason why those patients need a physical sitter."

During an interview on October 1, 2025, at 11:08 AM, with Registered Nurse 2 (RN 2), stated, "Before we initiate a tele-sitter or a sitter, we start with an assessment ...we don't need a doctor's order to implement a sitter, it's per a nurse's discretion ..." RN 2 further stated it was important to have accurate nursing assessments to justify the need for a tele-sitter or a sitter.

Based on interview and record review, the facility failed to ensure the nursing staff adhered to the policy and procedure (P&P) for fall prevention and management when one of 31 sampled patients (Patient 22) who was at high risk for fall, did not receive/document all fall prevention interventions (steps/actions taken to improve the situation).

This failure had increased the risk of patient falling which might have contributed Patient 22's unwitnessed fall and jeopardized the health and safety.

Findings:

During a review of patient 22's "Face sheet" (contains demographic data), dated March 10,2025, indicated, Patient 22 was admitted to the facility with the diagnosis of Pneumonia (a condition in which the air sacs in lungs get infected and collect fluids).

During a review of Patient 22's "history and Physical" (H&P), dated March 10,2025 ,the H&P indicated Patient 22 had a history of coronary artery bypass graft ( a surgical procedure to treat blocked coronary artery[ an artery in heart] with a healthy artery),diabetes mellitus( a condition in which blood sugar is high in blood) and ethanol (alcohol) dependence, blisters on feet ,cough. Patient 22 was diagnosed as acute with chronic heart failure (a condition in which heart does not pump as needed).

During a concurrent interview and record review on September 30,2025, at 8:55 AM, with Quality Management Staff (QMS 1), Patient 22's "electronic health record flowsheet" (EHRF- an electronic document where patient's assessment and other information are documented) was reviewed. The EHRF indicated ,Patient 22 was admitted on March 10,2025 at 10:32 PM, with the Morse fall risk assessment (a tool used to assess the risk for fall, scoring from 0-20 no risk or low risk, 25 - 44 medium risk, 45 or more is a high risk score) was scored as 50 (high risk).The QMS 1 stated, the interventions (steps taken to address the issue) for high fall risk were yellow fall risk band and yellow nonskid socks ,high fall risk sign on room, bed and chair alarms to signal patient movement ,consider using a fall mat.

During a concurrent interview and record review on September 30,2025, at 4:45 PM, with QMS 1, Patient 22's EHRF was reviewed. The EHRF indicated, on March 13,2025, at 7:30 AM and March 14,2025, at 7:30 AM only safety checks /rounds were completed for fall prevention interventions. The QMS 1 acknowledged that the EHRF is missing the documentation for fall prevention including the bed alarm was armed (activated on) and in use at the time of fall. The QMS 1 stated, the nurse' s are expected to complete the fall prevention interventions as per policy.

During a phone interview on October 1,2025, at 8:30 AM, with Registered Nurse 1(RN 1), RN 1 acknowledged that patient 22 was a high fall risk patient and was on high flow oxygen (a process in which oxygen therapy is applied through nose) via nasal canula (a tube through oxygen is delivered to the patient). RN 1 stated that patient 22 could be a patient considered to have a tele sitter (a person who remotely observes the patient through the camera for their safety) or a sitter at bedside for his safety.RN 1 stated he cannot recall whether the bed alarm was on. RN 1 further stated, when he saw Patient 22 on floor on March 14,2025, his oxygen canula was out from his nose and the patient was turning blue and unresponsive.

During a concurrent interview and record review on October 1,2025, at 9:36 AM, with Nurse Manger 1(NM 1) facility's policy and procedure (P&P) titled "Fall management prevention" dated June 6,2025 was reviewed. The P&P indicated, " ... purpose the purpose of this policy is to establish framework and guidelines for screening patient risk for falls utilizing valid and reliable tools assessing patient for specific fall risk factors, interviewing of patient history, implementing interventions for mitigating the risk for falls, actions in the event of a fall and post fall assessment and documentation. The screening, assessment and recommended interventions are designed to prevent and/or reduce the number and severity of falls in the classification of anticipated physiological falls. The goal of the initiative is prevention of injury .....iii. High risk for fall:2. Implement the following nurse driven interventions: ..d. Initiate bed and or chair alarm to signal patient movement ... j. consider using a fall mat. .l. Consider increasing purposeful rounding to anticipate and address patient needs ....r. If patient impulsive, unable to reorient and unable to retain instructions consider remote visual monitoring or constant observer". NM 1 stated, that the policy was not followed.