HospitalInspections.org

Based on interview, record review and policy review the facility failed to ensure that Medicare beneficiaries who were inpatients, received the Important Message from Medicare (IM, information about a patient's right to appeal discharge) for two patients (#9 and #41) of four Medicare patient records reviewed for the signed and dated IM within 48 hours after admission. The facility also failed to ensure the IM listed the correct Quality Improvement Organization (QIO, group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare) and their contact information, for one current patient (#41), of two current patients' IM reviewed. This had the potential to affect all Medicare beneficiaries admitted to the facility by preventing those patients from knowing their discharge rights and who to contact should they want to appeal their discharge from the facility. The facility census was 107.

Findings included:

1. Record review of the facility policy titled, "Medicare Appeal Rights," dated 10/2009, showed, "An Important Message From Medicare About Your Rights" was issued at admission or within 48 hours of admission. The patient's recipient/representative was given a copy of the signed form with the original placed in the "consent" section of the medical record.

2. Record review on 05/04/15 of Patient #9's medical record, showed that the patient was admitted on 04/24/15, but did not contain a signed and dated IM.

During an interview on 05/04/15 at 3:50 PM, Staff C, Registered Nurse, confirmed that the IM form was not in Patient #9's medical record.

3. Record review on 05/05/15, of Patient #41's medical record, showed that the patient was admitted on 04/30/15. The patient's IM contained outdated and incorrect information related to the QIO name and their contact information. The IM also showed that the patient gave verbal consent she received and understood her rights, but did not indicate a date those rights were provided to her.

During an interview on 05/07/15 at 11:15 AM, Staff DDD, Admitting Lead Clerk, stated that until the time Patient #41's IM was brought to her attention, she was unaware that there were IM forms with outdated QIO information in the facility. Staff DDD added that the Admissions Department had 24 hours "or so" to provide the IM to admitted patients, but if the form was not dated, there was no way to determine when the patient received their IM.



29047

Based on interview and policy review the facility failed to maintain a grievance committee of qualified personnel to review and resolve grievances in a timely manner. This had the potential to affect all patients/representatives who file a grievance to ensure the facility conducts a thorough and timely investigation. The facility census was 107.

Findings included:

Record review of the facility policy titled, "Complaint Mechanism/Grievance," dated 04/2013, showed the Grievance Committee shall include the Director of Quality/Risk Management, Chief Nursing Officer, Case Management, Social Services, and others as appropriate. The Grievance Committee will meet at least quarterly to analyze patterns and trends of complaints.

During an interview on 05/07/15 at 10:00 AM, Staff H, Director of Quality/Risk Management, stated that the facility had not had a grievance committee for two years.

Based on interview, review of facility grievances and policy review, the facility failed to establish a reasonable time frame for the investigation and resolution of a patient's grievance resulting in an average response time of 52 days for five (#45, #46, #47, #48 and #49) of five grievance files reviewed. This had the potential to affect all patients and or patient's representatives who file a grievance by denying them needed information regarding their grievance. The facility census was 107.

Findings included:

1. Record review of the facility policy titled, "Complaint Mechanism/Grievance," dated 04/2013, showed the facility had not established in writing any time frame for the facility's response to a grievance after it had been filed.

2. Record review of five grievances filed during the past six months showed the following:
- Patient #45 filed a grievance with the facility on 11/20/14 and the resolution letter was not sent to the patient until 01/06/15.
- Patient #46 filed a grievance with the facility on 04/13/15 and the resolution letter was not sent to the patient until 05/01/15.
- Patient #47 filed a grievance with the facility on 01/05/15 and the resolution letter was not sent to the patient until 03/17/15.
- Patient #48 filed a grievance with the facility on 12/15/14 and the resolution letter was not sent to the patient until 03/17/15.
- The representative for Patient #49 filed a grievance with the facility on 11/03/14 and the resolution letter was not sent to the representative until 12/03/14.

During an interview on 05/07/15 at 10:02 AM, Staff H, Director of Quality/Risk Management, confirmed that the current facility grievance policy did not contain any time frames regarding the correspondence with a patient/representative after the grievance was filed.

Based on observation, interview, record review and policy review, the facility failed to:
- Ensure staff accurately and consistently assessed the patients for fall risks (A0395).
- Ensure nurses going off the unit for meals or breaks followed policy and reported patient condition to a nurse who covered their patients while off the unit (A0395).
- Ensure each patient's Care Plan reflected individualized interventions for safety (A0396).

These deficient practices and systemic failures contributed to the facility's failure to meet the minimum requirements for the Condition of Participation: Nursing Services, and had the potential to place all patients at immediate risk for their health and safety, also known as immediate jeopardy (IJ).

The facility census was 107.

On 05/07/15, prior to the surveyor team exit, the facility provided a plan of correction sufficient to abate the IJ by immediately implementing the following:
- All current patients will be assessed for the risk of falls.
- To train all staff on the accurate use of the fall risk assessment tool.
- To revise forms and initiate policies to prevent further inaccurate fall risk assessments.
- To train all staff on the changes of all policies, systems, and/or forms prior to their next shift.
- To implement a scoring system that identified low, moderate, and high fall risk scores with appropriate care plan interventions related to each level.
-To ensure charge nurses followed the facility job description regarding the shift-to-shift report on their assigned units.
- To revise forms and initiate policies to prevent lack of charge nurse report and/or knowledge of patients' safety and fall risk.
- To implement an interdisciplinary "Code Fall" team which will respond to each fall in order to enhance investigation and/or interventions to prevent future falls.

All components of the plan of correction to be completed by 05/18/15.





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12450

Based on interview and record review, the facility failed to ensure there was one Chief Nursing Officer (CNO)/Director of Nursing (DON) who had oversight of and responsibility for all nursing services. This had the potential for nursing services to be provided in a manner that was inconsistent and without uniform supervision, which could lead to substandard nursing practice and poor patient outcomes. The facility census was 107.

Findings included:

1. Although requested, the facility failed to provide a policy related to Nursing Services oversight by a CNO/DON.

2. Record review of the facility form titled, "Nursing Organizational Chart," dated 03/2015, showed the CNO position was vacant, and that Staff A was titled "Interim Director of Nursing/Outpatient Services/Psych [Psychiatry]" and Staff D was titled, "Director of Nursing/Med Surg [Medical-Surgical]."

3. Record review of personnel files for Staff A and Staff D, showed that both staff signed job descriptions titled, "Director of Nursing," and that both reported to the CNO.

During an interview on 05/06/15 at 11:00 AM, Staff ZZ, Registered Nurse, was unable to identify who had overall responsibility for Nursing Services, and stated that Staff A was CNO and Staff D was DON.

During an interview on 05/06/15 at 11:30 AM, Staff QQ, Manager of Intensive Care Unit (ICU), sixth floor, and float pool (staff that can be utilized in various areas as needed for increased patient census and acuity), stated that both Staff A and Staff D shared nursing services oversight, that the CNO's responsibilities were divided between Staff A and Staff D, and that both Staff A and Staff D reported to Staff X, Chief Executive Officer (CEO).

During an interview on 05/05/15 at 3:55 PM, Staff A stated that he was Director over the Psychiatric Units, Intake and the Emergency Department. He stated that he reported directly to the CEO, and that he and Staff D were peers and that there was no interim CNO.

During an interview on 05/06/15 at 9:47 at AM, Staff D, stated that she had been in charge of the fifth and sixth floors, the ICU, and the float pool since approximately 03/2013. She stated that she currently reported to the CEO.

During an interview on 05/07/15 at 10:40 AM, Staff X stated that both Staff A and Staff D were nursing directors, both represented nursing on the administration team, that both were treated like CNOs, and both reported to him. Staff X stated that he left the CNO position open and unfilled because the corporate office planned to send a CEO from another corporate facility to function as CNO in August.

4. During record review of Human Resource files and concurrent interview on 05/07/15 at 12:55 PM, Staff GGG, Human Resource Manager, stated that Staff A had not been identified as the interim CNO and there was not an interim CNO.








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29511

Based on observation, interview, policy review and record review, the facility failed to:
- Ensure that patients received an accurate and consistent fall risk assessment/reassessment for two current patients (#32 and #40) of two current patients fall risk assessments reviewed, and two discharged patients (#38 and #39) of two discharged patients fall risk assessments reviewed.
- Ensure that patients who were determined to be high fall risk were protected from falls for two current patients (#32 and #40) of two current patients at risk for falls, and for two discharged patients (#38 and #39) of two discharged patient at risk for falls.
- Ensure nurses going off the unit for meals or breaks followed policy and reported patient condition to a nurse who covered their patients while off the unit for two discharged patients (#38 and #39) of two patients reviewed.
- Ensure that nursing staff followed physician orders for tracheostomy (a surgically created opening through the neck into the trachea or windpipe with a tube to provide an airway and to remove secretions from the lungs) care for one current patient (#12) of one current patient reviewed.
These failures had the potential to place all patients admitted to the facility at risk for repeated falls, injury, and/or death. These failures also had the potential to prevent physician's orders from being fulfilled. The facility census was 107.

Findings included:

1. Record review of the facility's document titled, "Fall Risk Precautions," dated 05/2013, provided guidelines to assess and identify those patients at risk for fall and to implement interventions to reduce the risk of patient falls and associated injuries with the following procedures:
- Upon admission to the hospital system, the nursing staff will complete the facility Fall Risk Assessment Form and document the score on the appropriate documentation form.
- Interventions will be planned and implemented according to each patient's risk level. These will be documented on the interdisciplinary plan of care.
- The assessment and/or re-assessment will be documented on the Fall Risk Assessment. The interdisciplinary plan of care will be reviewed and/or updated a minimum of every 24 hours and as needed.

2. Record review of the facility incident/accident reports (reports of unexpected events) from 01/01/15 through 05/05/15 showed the facility had 119 falls, facility-wide, with injuries classified as the following:
- Head injuries, five (one who ultimately died, Patient #38);
- Abrasion injuries, four;
- Laceration injuries, five;
- Skin tear injuries, two;
- Ankle/foot strain injuries, one;
- Mouth injuries, one; and
- Other injuries, two (including one hip fracture, Patient #39).

Falls per unit, from 06/01/14 through 12/31/14, were as follows:
- Three East Psychiatric 33;
- Three West Psychiatric 18;
- Four Psychiatric 26 falls; and
- Gero Psychiatric 71 falls.

3. Record review of facility's undated policy titled, "Reporting on and off the work lane," showed the following directives for staff:
-Before leaving the unit the staff member shall report to the charge nurse, clinical leader or alternate that they are leaving and for how long;
-Include in the report any patients you are responsible for and any precautions the patients are on;
-Report the patient treatments that are needed;
-Report any other information that would help provide safe care for the patient while you are off the unit;
-Upon returning to the unit you shall report back to the charge RN or clinical leader; and
-The charge RN shall notify you of any changes or care the patients need.

4. Record review of the Psychiatric Medical Clearance, emergency room record and clinical history for discharged Patient #38 showed he had been a patient on 02/04/15 and had sustained two falls during that time. Patient #38 was admitted again on 03/25/15 from a nursing home with a diagnosis of Alzheimer's (a degenerative brain disease of unknown cause and the most common form of dementia, which is a loss of mental ability severe enough to interfere with normal activities of daily living [ADL's - basic self-care tasks such as eating, dressing, grooming, etc.], lasting more than six months) disease with behavior disturbance (behave in a manner that may place themselves and others in danger) to the Gero Psych Unit. The patient fell on 03/29/15 and sustained an injury above his right eyebrow that required five stitches.

Record review of the document titled, "Fall Risk Evaluations," for discharged Patient #38 with Staff A, RN, Director of Nursing over Psychiatric Units and the Emergency Department, showed the following (any score greater than 10 indicated patient was a High Fall Risk):
- 03/27/15 - total scores of two 12-hour shifts were 12 and 8;
- 03/28/15 - total scores of two 12-hour shifts were 10 and 8;
- 03/29/15 - total scores of two 12-hour shifts were 8 and 14 with note: FELL OUT OF CHAIR TODAY; (patient had a laceration to the head and required five stitches)
- 03/30/15 - total scores of two 12-hour shifts were 16 and 17; (no note about 1:1 status); and
- 03/31/15 - total scores of two 12-hour shifts were 13 and 16; (no note that 1:1 status was discontinued).

Record review of the physician's order for Patient #38 showed an order written on 03/30/15 at 12:11 PM by Staff III, Psychiatrist, for a sitter (an individual assigned to give a patient individual 1:1 attention as to their needs, especially safety). The order had a stop date of 03/31/15 at 12:15 PM.

During an interview on 05/06/15 at 1:00, Staff JJ, Medical Doctor (MD), Patient #38's physician, stated that Staff III no longer worked at the facility. He stated that a sitter order would normally be written for a 24-hour period and renewed at that time if necessary. He stated that he could not speak to the reason the sitter order was discontinued.

Record review of the Rapid Response Team Record dated 03/31/15 showed the Team was called at 8:50 PM to the Gero Psych Unit. Patient #38 was observed on the floor on his back with active bleeding noted from his right ear and the back of his head, less than nine hours since he was removed from sitter status.

Emergency Department Summary for Patient #38 showed that he had fallen from his wheelchair on 03/31/15 in the Gero Psych Unit. He was taken to the Emergency Department at 10:37 PM with blood from his right ear and the back of his head. He was transferred to another facility where he was diagnosed with a skull fracture and brain death. Patient #38 was pronounced dead on 04/01/15 at 12:09 PM.

5. Record review of Patient #39's discharged medical record showed that she was admitted to facility on 01/27/15 for aggressive behavior at the nursing home with a psychiatric history of dementia, schizophrenia (mental disorder characterized by false thoughts, inappropriate feelings, and withdrawal from reality), bipolar disorder (a disease characterized by periods of elevated mood and periods of sadness), and a medical history of high blood pressure, chronic pain and osteoarthritis (joint disease). The patient was noted to be a maximum assist with ADL's and transfer to and from bed to a wheel chair.

Record review of the document titled, "Fall Risk Evaluations," for discharged Patient #39 showed the following:
- On 03/02/15 total scores of two 12 hour shifts were 20 and 11;
- On 03/03/15 total scores of two 12 hour shifts were 20 and 11;
- On 03/04/15 (the day the patient fell) total scores of two 12 hour shifts were 20 and 20. Patient was then transferred to another hospital for surgery.

Record review of a facility incident report showed that on 03/04/15 at approximately 1:00 PM Patient #39 was found in her room, on her back, and screamed that both hips hurt. Additional documentation indicated that the patient fell and fractured her left hip.

During an interview on 05/04/15 at 3:05 PM, Staff Y, RN stated that she was on the unit at the time the patient fell. She stated that three nurses staffed the unit on that shift. The nurse assigned to Patient #39 was at lunch. Staff Y stated that she knew the other nurse was at lunch but had not received report on this patient. Staff Y stated that at some point the patient must have wheeled herself back to her room although she did not notice her leave the multipurpose room. Staff Y stated that she heard the patient scream, went to the patient's room and found her on the floor between her wheelchair and the bed. The patient cried and screamed that her hips hurt. Staff Y stated that RN's don't always get report when other RN's go to lunch or off the floor.

During an interview on 05/05/15 at 10:30 AM, Staff Z, RN, stated that she was the nurse assigned to care for Patient #39 on the day she fell. Staff Z stated that she had gone to lunch and had advised the other two nurses that she was going, and assumed that one or both of them would watch her patient. Staff Z stated that the patient was in the multipurpose room when she left for lunch. When she returned from lunch she was told the patient fell.

During an interview on 05/06/15 at 1:25 PM, Staff PP, Physician that cared for Patient #39, stated that falls in the geriatric psychiatric patients are a big concern. He stated that he was not aware of what the specific interventions are for patients assessed as a fall risk but does believe that patients at higher risk should have increased interventions. After being informed of the facility protocol, Staff PP stated he was surprised the process did not initiate increased interventions with increased risk.

During an interview on 05/06/15 at 9:40 AM Staff I, Manager Gero Psych Unit, stated she believed the cause of this fall (and others) was that her staff had lost focus on the geriatric patients. She stated that the geriatric psychiatric population was fragile, on many medications and had lots of comorbidities (medical issues). She worked with staff to understand that it was everyone's responsibility to prevent falls not just react after one happened. Staff I stated that the current Fall Risk process did not include any increase in interventions based on a "high risk for fall" assessment. Staff I stated that there was no formal report off process when a staff member was going to lunch.

During a telephone interview on 05/06/15 at 11:25 AM, Staff FF, RN, stated that at the time Patient #39 fell she was at nurses station with Staff Y. Staff FF was aware that the nurse assigned to Patient #39 was at lunch, but she had not received report on this patient. Staff FF stated that she wasn't sure when the patient left the multipurpose room and went to her bedroom. Staff FF heard the patient scream and went to the patients' room. Staff FF stated that the patient was on the floor between her wheelchair and her bed. Staff FF stated it was not unusual to not get a formal report on the patients when a nurse went to lunch, "We all know all the patients."

During an interview on 05/06/15 at 3:00 PM, Staff H, Director of Quality and Risk Management, stated that after the fall was investigated she believed that the cause of the fall was "human error, the nurses are not paying attention to the patients".

During an interview on 05/06/15 at 8:30 AM, Staff HH, RN, Charge Nurse on Gero Psych, stated that she was only given report on the patients assigned to her. As an example, she stated that out of nine patients on the unit she would be assigned two patients and she would not be given a status report on the other seven patients as to their health or safety needs. She stated that the other nurse assigned to the unit would get report only on her assigned patients and the same for the Patient Care Technician(s) (PCTs). She stated that she was not aware of the other patients' health or safety status even though she was responsible for all the patients' care and staff assignments. Staff HH stated that she was often the only person on the unit when other staff left to prepare medications, get supplies, personal time or breaks. She stated that Patient #38 fell on 03/31/15 and later died from his injuries. She was left on the unit by herself and did not know of his fall risks or that he had fallen the day before and had just been taken off a 1:1 (by physician's order and facility policy, a patient would be required to have a staff member within arm's reach at all times) status.

During an interview on 05/06/15 at 10:05 AM, Staff A stated that he was not aware that nursing staff didn't receive report on all patients' health and safety status.

6. Record review of Patient #32's current medical record showed the patient was admitted on 04/15/15 from the nursing home and had a history of dementia, and high blood pressure. The patient was noted to be a maximum assist due to dementia, weakness, poor communication and limited mobility.

Record review of Fall Risk Evaluations showed the following:
- 05/01/15 total scores of two 12-hour shifts were 18 and 19;
- 05/02/15 total scores of two 12-hour shifts were 13 and 10;
- 05/03/15 total scores of 14 and (immediately after fall) 16 and a lap buddy (device placed in front of patient while in wheel chair to prevent patient from standing) was applied;
- 05/04/15 total scores of 13, no mention of a lap buddy in place, no night shift assessment; and
- 05/05/15 total scores of 18, no mention of a lap buddy in place.

Observation of video record from 05/03/15 at 3:30 to 3:45 PM showed Patient #32, in the multipurpose room, walked slowly with a wheelchair in front of him (for balance). At one point the patient stopped, appeared to lock the wheels and moved slowly around the chair. The chair began to slide and the patient became unbalanced and fell backwards onto his buttocks. At that point a staff member that was seated in the room responded to the patient.

During an interview on 05/05/15 at 10:15 AM Staff I, Manager, stated that Patient #32 fell over the past weekend and she had reviewed a video record showing the fall. Staff I, stated that the Fall Risk Evaluation scores were subjective and did seem to be inconsistent and inaccurate in the score. Staff I stated that no additional interventions were currently instituted for increased fall risk based on fall assessments. All patients at risk for fall were placed in yellow nonskid socks, had a yellow mark on their armband and had a sign above their bed. Staff I stated that the "Fall Huddle Documentation Form" was not completed for this event, "but it should have been". She stated that this form documented the situation at the time of fall and alerted administration of the fall that occurred. Staff I stated that the form was initiated as part of the action plan related to recent falls and was disappointed that it wasn't completed. Staff I stated that after review of the video, and after all of the education and discussion about falls in the department, she would have expected the staff member seated in the multipurpose room to get up and assist Patient #32 as he shuffled slowly with the wheel chair in front of him. "Closer observation may have prevented this fall".

During a telephone interview on 05/06/15 at 11:25 AM, Staff FF, stated that at the time Patient #32 fell she was the RN assigned to the patient. Staff FF stated she was not in the multipurpose room at that time but was told of the fall when she returned to the area.

During a telephone interview on 05/07/15 at 10:30 AM, Staff OO, PCT, stated that she was present in the multipurpose room when Patient #32 fell. Staff OO stated that the patient tried to get around his wheelchair when it slipped a little and he fell backwards on his butt. She stated she tried to watch all the patients and keep them safe and that she knows the yellow socks indicate the patient is a fall risk but "you can't watch them all".

7. Record review of current Patient #40's "Clinical CareStation Inquiry Flowsheet" (fall risk assessment tool used in the Intensive Care Unit, ICU), showed inconsistent nursing assessments for fall risk, which varied significantly from shift to shift. The assessments showed the following:
- From 04/29/15 through 05/05/15 there were 24 assessments with total scores of zero, two and/or four.
- However additional assessments showed: on 05/01/15 one assessment timed from 10:00 AM until 8:00 PM showed the patient's fall risk score changed to 18 (a high fall risk) but from 8:00 PM through 8:00 PM on 05/02/15 the patient's fall risk score changed to six (moderate risk for fall).
- From 05/02/15 from 8:00 PM to 8:00 PM on 05/03/15 a fall risk score of nine (moderate fall risk).
- 05/03/15 from 8:00 PM through 6:00 AM on 05/04/15 fall risk of 18 (high fall risk) after the patient fell.
- 05/04/15 at 6:00 AM until 8:00 AM changed to 14 (high fall risk)
-05/04/15 at 8:00 AM through 8:00 PM changed to 23 (high fall risk).

Record review of Patient #40's "Daily Focus Assessment Report," (physical assessment tool used in the ICU) showed that from 05/03/15 at 8:00 PM until 05/04/15 at 6:00 AM (shift the patient fell on), Staff HHH, RN, documented every hour, on the hour, that she assessed Patient #40. Staff HHH's assessments showed that the patient was alert and oriented (knew who she was, where she was, and what was going on around her), but further assessments contradicted one another when she documented that the patient was both strong and weak, and calm, but anxious and restless.

During an interview on 05/07/15 at 2:55 PM, Staff HHH, stated that prior to Patient #40's fall on 05/04/15 at 5:50 AM (fall risk score at the time of the fall was 9, moderate), the patient exhibited confusion (although she documented the patient was alert and oriented ), "would start weird conversations", had difficulty with short term memory throughout the night, and poor impulse control (these findings would have increased the patient's fall risk score to high). Staff HHH stated that although her documentation indicated that she assessed the patient every hour, she only assessed the patient every two hours, and felt that the additional documentation was in error. Staff HHH stated that the fall risk tool was inaccurate, because she noticed there were significant changes or fluctuations in the overall patient fall risk score, depending on the nurse who completed the assessment.

8. Record review of Patient #12's H&P showed that she had a past medical history of respiratory failure (a medical emergency when there is a decrease in the level of oxygen in the blood or an increase in the level of carbon dioxide causing lung failure) with placement of tracheostomy.

Record review of Patient #12's physician orders dated 04/21/15 showed for tracheostomy care to be done every four hours.

Record review of Patient #12's medical record showed the following nursing interventions:
- Tracheostomy care provided on 04/24/15;
- Tracheostomy care provided on 05/02/15;
- Tracheostomy care provided on 05/03/15.

Even though the patient had an order for tracheostomy care to be done every four hours, it was documented that the patient only received tracheostomy care a total of three times during her 14 days of admission with 84 opportunities for tracheostomy care. No documentation was found that the patient had refused tracheostomy care at any time.

During an interview on 05/05/15 at 2:45 PM, Staff FFF, RN, stated that she was assigned Patient #12 but that the patient had refused her tracheostomy care for that day. She stated she had not documented that the patient had refused care. Staff FFF also stated that she was unsure of where to document tracheostomy care had the patient allowed her to have performed the care.

During an interview on 05/05/15 at 2:25 PM, Staff F, RN, Clinical Leader, verified that Patient #12 should have received tracheostomy care every four hours per physician order but could not verify that this was being done per medical record review.




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29047




32280

Based on interview, record review and policy review, the facility failed to ensure that Care Plans for patients assessed as high risk for falls, or who had previously fallen, were revised to include additional fall risk interventions for two current patients (#32 and #40) of five current patient Care Plans reviewed and two discharged patients (#38 and #39) of two discharged patient Care Plans reviewed for fall risk interventions. These failures led to the immediate risk of patients' health and safety, and had the potential to lead to the risk of all patients' health and safety who were at risk for falls. The facility also failed to ensure Care Plans were individualized with patient specific goals and interventions for six current patients (#12, #31, #40, #41, #42 and #44) of 10 current patient Care Plans reviewed for goals and interventions (unrelated to falls). This had the potential to affect all patients, when the patients' medical or psychological needs go unidentified, and lead to poor patient outcomes. The facility census was 107.

Findings included:

1. Record review of the facility's undated "Nursing Scope of Services," showed that the Care Plan:
- Was an individualized written document developed using the nursing process;
- Was the responsibility of the Registered Nurse (RN); and
- Involved all staff, who were to refer to this resource of patient information and direction.

Record review of the facility's policy titled, "Treatment Plan (the same as a Care Plan on other units)," dated 08/2014, showed the following:
- The Treatment Plan will be initiated by an RN for all admitted patients in the Emergency Department and Intake awaiting an inpatient bed.
- The treatment plan will be individualized based upon a comprehensive assessment of patient needs within seventy-two (72) hours of each admission.
- The RN will initiate a problem entry for any problems identified during the nursing assessment process.
- Individualization and modification of the Nursing Care Plan may be completed by the RN/Licensed Practical Nurse (LPN) staff.
- The Care Plan is an individualized written document developed using the nursing process. The development and follow through becomes the ultimate responsibility of the RN, but all nursing staff involved were to contribute individualization, and all staff are to refer to this resource of patient information/direction.
- Review and evaluation of Care Plan is expected to be conducted at each shift by the RN/LPN who can best determine patient progress or outcome as a basis for modification or revision.

Record review of the facility's document titled, "Fall Risk Precautions," dated 05/2013, provided guidelines to assess and identify those patients at risk for fall and to implement interventions to reduce the risk of patient falls and associated injuries with the following procedures:
- Upon admission to the hospital system, the nursing staff will complete the facility Fall Risk Assessment Form and document the score on the appropriate documentation form.
- Interventions will be planned and implemented according to each patient's risk level. These will be documented on the interdisciplinary Care Plan.
- The assessment and/or reassessment will be documented on the Fall Risk Assessment. The interdisciplinary Care Plan will be reviewed and/or updated a minimum of every 24 hours and as needed.

2. Observation on 05/04/15 at 2:15 PM on the Geriatric (Gero) Psychiatric (Psych) Unit showed:
- All patients wore yellow non-slip/skid socks;
- All patients had on a yellow clip on armband; and
- Patient rounding was completed on all patients every 15 minutes.

During an interview on 05/04/15 at 2:40 PM, Staff K, LPN, on Gero Psych, stated that she had just completed the rounding (checking on each patients location and safety) for the patients. She stated that all of the patients on the unit were considered high risk for falls and that all of the patients were rounded on every 15 minutes.

During an interview on 05/04/15 at 3:00 PM, Staff Y, RN, stated that all the patients on the Gero Psych Unit have diagnoses of Alzheimer's disease or Dementia (Alzheimer's is a degenerative brain disease of unknown cause and the most common form of dementia, which is a loss of mental ability severe enough to interfere with normal activities of daily living [ADL's, which are basic self care tasks such as eating, dressing, grooming, etc.]) Staff Y stated that all patients had been assessed as high risk for falls.

During an interview on 05/06/15 at 8:30 AM, Staff HH, RN, Charge Nurse on Gero Psych, stated that fall risks were completed on each patient each shift but that there were no guidelines that corresponded fall risk scores to fall interventions for the patients' Care Plans.

3. Record review with Staff A of the document titled, "Fall Risk Evaluations," for discharged Patient #38 showed the following: (Any patient's score greater than 10 indicated the patent was a high fall risk.)
- On 03/27/15 total scores of two 12-hour shifts were 12 and 8;
- On 03/28/15 total scores of two 12-hour shifts were 10 and 8;
- On 03/29/15 total scores of two 12-hour shifts were 8 and 14 with note: FELL OUT OF CHAIR TODAY; (patient had a laceration to the head and required five stitches)
- On 03/30/15 total scores of two 12-hour shifts were 16 and 17; (no note about 1:1 status); and
- On 03/31/15 total scores of two 12-hour shifts were 13 and 16; (no note that 1:1 status was discontinued).

Record review of the documents titled, "Patient Care Plans" for Patient #38 showed the following interventions for fall precautions for the dates of 03/27/15 through 03/31/15:
- Yellow clip on armband;
- Fall precautions sign above the bed;
- Yellow Non-slip/skid socks;
- Frequent Rounding; and
- Educate Patient/Family (Patient #38 was diagnosed with Alzheimer's disease which would make education to the patient very limited or impossible).
Patient #38's Care Plan was never updated with any new interventions after his fall on 03/29/15.

Record review of the Emergency Department Summary for Patient #38 showed that he had fallen from his wheelchair on 03/31/15 in the Gero Psych Unit. He was taken to the Emergency Department at 10:37 PM with blood from his right ear and the back of his head. He was transferred to another facility where he was diagnosed with a skull fracture and brain death. Patient #38 was pronounced dead on 04/01/15 at 12:09 PM.

During an interview on 05/06/15 at 8:30 AM, Staff A, Director of Nursing over Psychiatric Units and the Emergency Department, stated that the Fall Risk Evaluations for Patient #38 showed inconsistency in charting. He stated that if all of the patients have all of the same interventions then there is no individualized treatment plan (Care Plan) for any individual. He stated he did not know that the Fall Risk Assessment did not have guidelines that corresponded to interventions on the Care Plan.

4. Record review of discharged Patient #39's medical record showed that she was admitted to facility on 01/27/15 for aggressive behavior at the nursing home with a psychiatric history of dementia, schizophrenia (mental disorder characterized by false thoughts inappropriate feelings, and withdrawal from reality), bipolar disorder (a disease characterized by periods of elevated mood and periods of sadness), and a medical history of high blood pressure, chronic pain and osteoarthritis (joint disease). The patient was noted to be a maximum assist with ADL's and transfer to and from bed to a wheel chair.
Record review of the document titled, "Fall Risk Evaluations," for Patient #39 showed the following:
- On 03/02/15 total scores of two 12 hour shifts were 20 and 11;
- On 03/03/15 total scores of two 12 hour shifts were 20 and 11;
- On 03/04/15 (the day the patient fell) total scores of two 12 hour shifts were 20 and 20.

Record review of a facility incident report (report of unexpected event) showed that on 03/04/15 at approximately 1:00 PM Patient #39 was found in her room, on her back, and screamed that both hips hurt. Additional documentation indicated that the patient fell and fractured her left hip.
During an interview on 05/05/15 at 10:30 AM, Staff Z, RN, stated that she was the nurse assigned to care for Patient #39 on the day she fell. Staff Z stated that Care Plans should be updated with a change in condition but the fall risk interventions had already been implemented so no change was indicated.
During an interview on 05/06/15 at 9:40 AM Staff I, Manager Gero Psych Unit, stated that she believed the cause of this fall (and others) was that her staff had lost focus on the geriatric patients. She stated that the geriatric psychiatric population was fragile, on many medications and had lots of comorbidities (medical issues). Staff I stated that the current Fall Risk Care Plan process did not include any increase in interventions based on a "high risk for fall" assessment. All patients at risk for fall were placed in yellow nonskid socks, had a yellow clip on armband and had a sign above their bed.

5. Record review of Patient #32's medical record showed the patient was admitted on 04/15/15 from a nursing home and had a history of dementia and high blood pressure. The patient was noted to be a maximum assist due to dementia, weakness, poor communication and limited mobility.
Record review of Fall Risk Evaluations showed:
- On 05/01/15 total scores of two 12-hour shifts were 18 and 19;
- On 05/02/15 total scores of two 12-hour shifts were 13 and 10 (unsteady gait noted);
- On 05/03/15 total scores of 14 and (immediately after fall) 16 and a lap buddy (device placed in front of patient while in wheel chair to prevent patient from standing) was applied;
- On 05/04/15 total scores of 13, no mention of a lap buddy in place, no night shift assessment; and
- On 05/05/15 total scores of 18, no mention of a lap buddy in place.

Observation of video record dated 05/03/15 from 3:30 to 3:45 PM showed Patient #32, in the multipurpose room. The patient walked slowly with a wheelchair in front of him (for balance). At one point the patient stopped, appeared to lock the wheels and moved slowly around the chair. The chair began to slide and the patient became unbalanced and fell backwards onto his buttocks. At that point a staff member that was seated in the room responded to the patient.
During an interview on 05/05/15 at 10:15 AM Staff I, Manager, stated that Patient #32 fell the previous day and she had reviewed a video record of the fall. Staff I stated that the Fall Risk Assessment scores are subjective and there were inconsistencies and inaccuracies in documentation. Staff I stated that no additional interventions were currently indicated for increased high risk for falls. Staff I stated that Care Plans should always be addressed and updated based on a change in condition or a change in the evaluation. Staff I stated that the Care Plans should trigger increased interventions when the fall risk score increased. Staff I stated that the "Fall Huddle Documentation Form" was not completed for this event, "but it should have been". She stated that this form reviews the situation at the time of fall and alerts administration of the fall. Staff I stated that the form was initiated 04/15 as part of an action plan related to recent falls and was disappointed that it wasn't completed. Staff I stated that after review of the video related to this recent fall, and after all of the education and discussion about falls in the department, she would have expected the staff member sitting in the multipurpose room to get up and assist Patient #32 as he shuffled slowly with the wheel chair in front of him. "That may have prevented this fall".
During a telephone interview on 05/06/15 at 11:25 AM, Staff FF, RN, stated that at the time of Patient #32's fall she was the RN assigned to the patient. Staff FF stated that she was not in the multipurpose room at that time but was told of the fall when she returned to the room. Staff FF stated that she forgot to initiate the Fall Huddle Documentation Form." Staff FF stated that there were not any additional interventions added to the Care Plan other than those that everyone received.

6. Record review of current Patient #40's medical record showed the nursing "Daily Focus Assessment Report" (record of the patient's nursing assessment, which focused on specific physical or psychological areas), showed the patient fell on 05/04/15 at 5:50 AM. The patient's Care Plan was not revised after the patient fell, to include additional interventions to prevent the patient from further falls.

During an interview on 05/05/14 at 4:11 PM, Staff YY, RN, verified there were no changes made to the patient's Care Plan after the patient fell.

During an interview on 05/07/15 at 2:55 PM, Staff HHH, RN, stated that she made no changes to Patient #40's Care Plan before the patient fell, even though the patient exhibited confusion, "would start weird conversations", had difficulty with short term memory throughout the night, and poor impulse control. Staff HHH added that she did not change the patient's Care Plan after the patient fell, because the patient was already on fall precautions.

7. Record review of current Patient #31's medical record showed. She was admitted to the Gero psych unit on 04/17/15 for acute bizarre, self-harming behavior with previous medical history of mitral (heart) valve replacement and CHF (congestive heart failure, fluid buildup around the heart):
- On 04/27/15 the medical physician documented CHF was stable with no additional orders;
- On 04/30/15 the medical physician ordered a cardiology consult (heart specialist to examine patient);
- On 04/30/15 the cardiology consult was completed and it was suggested to increase diuresis (body fluid removed by medication) and CPAP (Continuous Positive Air Pressure, a machine that helps person who has sleep apnea [stops breathing] to breathe more easily while sleeping);
- On 05/01/15 the medical physician ordered sleep study and Oxygen via nasal cannula (tube placed in nostrils);
- On 05/04/15 medical physician documented that patient was more congested today, CHF was exacerbated (increased), sleep study was completed, requested respiratory therapy to initiate CPAP and determine settings, and ordered increased furosemide (medication to remove fluid), twice daily.


Record review of Patient #31's Care Plan from 04/30/15 to 05/05/15 at 11:00 AM, showed no individualized interventions related to the patient's CHF exacerbation (increased symptoms), sleep apnea, CPAP, increased fluid retention, addition of oxygen therapy, and increased medication.
During an interview on 05/05/15 at 10:00 AM, Staff I, Manager of Gero Psych Unit stated that based on the patient's physical symptoms, change in condition, and physicians documentation, the Care Plan should have been updated.
During an interview on 05/05/15 at 10:30 AM, Staff AA, RN that cared for Patient #31, stated that the change in condition should have triggered a Care Plan update and possible interventions.

8. Record review of current Patient #40's medical record showed:
- A History and Physical (H&P) dated 04/29/15, with documentation that the patient complained of back pain in the left scapula (shoulder blade) area and left shoulder.
- The nursing "Admission Assessment Report" (record of the patient's nursing admission assessment) dated 04/29/15, with documentation that the patient complained of upper left back pain, rated 8 out of 10 on a 1 to 10 scale (with 10 being the most painful).
- The nursing "Daily Assessment Inquiry" (record of the patient's daily nursing assessment) showed the patient complained of back pain two times on 04/30/15, three times on 05/01/15, once on 05/02/15 and six times on 05/04/15.
- The Care Plan did not indicate pain as a problem for the patient, and there were no interventions to address the patient's pain.

During an interview on 05/05/14 at 4:11 PM, Staff YY, RN, verified that pain wasn't addressed on Patient #40's Care Plan.

9. Record review of current Patient #41's H&P dated 04/30/15, showed that the patient complained of pain in the left side and lower back and ribs, painful urination and chronic back pain. The Care Plan did not indicate pain as a problem for the patient, and there were no interventions that addressed the patient's pain.

10. During an interview on 05/05/15 at 9:20 AM, Patient #42 stated that she had pain "all over" and rated her pain 8 out of 10 on a 1 to 10 scale.

Record review of Patient #42's H&P dated 05/04/15, showed that the patient complained of back pain and had a history of chronic pain. The Care Plan did not indicate pain as a problem for the patient, and there were no interventions that addressed the patient's pain.

11. Record review of Patient #12's H&P, dated 04/04/15, showed the patient had a history of respiratory failure (a medical emergency when there is a decrease in the level of oxygen in the blood or an increase in the level of carbon dioxide causing lung failure) with tracheostomy (a surgically created opening through the neck into the trachea [windpipe] with a tube to provide an airway and to remove secretions from the lungs).

Record review on 05/04/15 of the patient Care Plan showed no problems had been identified or interventions initiated in relation to her tracheostomy.

During an interview on 05/04/15 at 3:40 PM, Staff F, Clinical Leader, verified that the patient's tracheostomy was not addressed in her Care Plan but should have been.

12. Record review of Patient #44's medical record showed he was admitted on 04/18/15 for schizophrenia (a mental disorder characterized by abnormal social behavior and failure to recognize what is real) and personality disorder (mental illness that involve long-term patterns of thoughts and behaviors that are unhealthy and inflexible).
Observation and concurrent interview on 05/05/15 at 10:00 AM showed Patient #44's room (#301) window was broken. Patient #44 stated that he had broken the window because he wanted out.

Record review of an incident report dated 05/01/15 at 5:50 PM showed that Patient #44 had lifted the wooden frame of the bed and slammed it against the screen of the window in his room that broke the screen and window.

Record review of the patient's Care Plan on 05/05/15, initiated on 04/20/15, showed that the patient was considered at risk for violence towards others. Staff failed to update the Care Plan with pertinent interventions and a goal to prevent future aggressive behaviors following the behavior that resulted in the broken window.

During an interview on 05/05/15 at 11:00 AM, Staff F, RN, Clinical Leader, stated that the Care Plan should have been updated after his behavioral outburst.

During an interview on 05/06/15 at 8:19 PM, Staff KK, RN, stated that she had been assigned to Patient #44 on the night he had broken the window. She was unsure if the patient's Care Plan had been updated, but it should have been after his behavioral outburst.



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