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Based on interview and document review, the facility did not have a standard process for notifying family members when patient falls occurred. Lack of documentation regarding falls and family notification of falls was found in 5 of 6 medical records reviewed (Patients #2, #3, #4, #5, and #13).

This failure created the potential for patients' health status to be unknown to family members who were to be included in patients' care and decision-making.

FINDINGS:

POLICY

According to facility policy, Fall Prevention, as fall prevention measures are implemented, patients and family members will be given a Falls Prevention Education Sheet, patients and families will be encouraged to participate in fall prevention practices, and if a patient experiences a fall in the facility, family will be notified of the fall.

According to facility policy, Occurrence Reporting Process, events, including patient falls, will be reported to the family or responsible party as soon as possible after stabilization of the patient. Staff will complete a reporting form and will document the event in the patient's medical record. Staff will also document notification of the event to the patient's physician and family or responsible party.

1. The facility did not have a standard process to ensure family members, including patient representatives, were contacted after patients experienced falls in the facility in 5 of 6 medical records reviewed. In 3 of 5 medical records reviewed, there was no documentation that a fall had occurred.

a) On 10/29/14 at 1:55 p.m., review of patient medical records and occurrence reports was conducted with the Chief Clinical Officer (CCO). The records for Patient's #2, #3, #4, #5, and #13 showed the patients experienced a total of 11 falls during hospitalization.

Three fall events revealed no documentation of the fall in the patient's medical record and no documentation the family was notified of the fall on the occurrence report or in the medical record (Patients #2, #4, and #13).

Six fall events revealed no documentation on the occurrence report or in the medical record that family were notified of the fall (Patients #2, #3, #4, #5, and #13).

b) On 10/28/14 at 2:51 p.m., an interview was conducted with the CCO who stated someone from the facility's staff would be required to inform the family if a patient experienced a fall. S/he stated it could be a nurse, physician, or other staff member who would make the call to the patient's family, and the call would be documented on the occurrence report and in the patient's medical record. The CCO stated family were asked upon admission if they wanted to be called and awakened at night with patient updates, which would include falls, and this information was placed on a "sticky note" at the front of the patient's medical record. S/he stated the sticky notes were not part of the medical record and the instructions of when staff should call family were not documented anywhere in the medical record. The CCO stated when patients listed more than one family member to contact, staff were not required to phone all family members but only the primary contact which was documented in the patient's medical record on an admission form.

The CCO stated it was the facility's policy and staff training that family members would be informed of patient events and documentation of the date and time of contact was required in the patient's medical record. S/he stated it would likely be documented in a nurses note but there was no exact instruction provided to staff regarding where to document this information.

The CCO confirmed the lack of documentation when s/he reviewed all documents with the surveyor.

The CCO stated s/he was unaware the facility's policy regarding family notification of patient falls was not being carried out by staff. The CCO stated no audits were conducted to ensure this requirement was completed and documented in patient's medical record. S/he confirmed this was a patient rights issue and lack of notifying families of falls prevented family members from having a complete understanding of patient care and care planning.

c) On 10/27/14 at 3:18 p.m., an interview was conducted with Registered Nurse (RN) #3 who stated if a patient experienced a fall in the facility, s/he would contact the patient's family in person or by phone to inform family of the event. RN #3 stated this was facility policy and his/her training. RN #3 stated if a fall occurred late at night or very early in the morning, s/he would still phone the family to report the event and would not wait until later in the morning or later in the day. RN #3 stated s/he would report any type of fall to family (witnessed, unwitnessed, fall with injury, or fall without injury). RN #3 stated per facility policy and his/her orientation to the facility, s/he would complete an occurrence report and document contacting the patient's physician and family and would also document the fall in the electronic medical record.

d) On 10/28/14 at 3:25 p.m., an interview was conducted with RN #5 who stated per his/her training in the facility if a patient experienced a fall, family would be contacted "within a few hours" by a nurse at the instruction of the Charge Nurse.

Based on observations, interviews, and document review, the facility failed to provide well organized delineation of responsibilities for patient care. The facility failed to provide a process to nursing staff to ensure patients at risk for falls were assessed consistently and monitored per an assessment tool and per the facility's policy.

This failure created the potential for patients at risk for falls to be unknown to direct care staff and to possibly receive less fall risk prevention and monitoring than needed to ensure patient safety.

FINDINGS:

According to facility policy, Fall Prevention, patient care staff will assess, plan and implement interventions to reduce falls for patients throughout hospitalization. Per the policy:
Preventive Measures: Score of 10 or less
Low-Moderate Fall Precautions: Score 11-20
High Risk: Score greater than 21 (or when ordered by the physician)
For low-moderate risk and high risk patients, a yellow FALL sign will be placed on the door jamb, alerting all staff that the patient is a fall risk.

According to the Morse Fall Risk Assessment tool, located in each patient electronic record and use by nursing staff, for a score of less than or equal to 51, staff will implement universal fall precautions and for a score greater than 51, staff will implement high fall risk precautions.

According to facility policy, Admission of a Patient, the admitting nurse will place the patient identification wristband on the patient and will attach all other applicable colored bands to the patient's wrist.

1. The facility did not clearly define which member of the patient care team was responsible for placing fall risk placards on the outside of patients' doors to indicate to all staff that patients were at risk for falls. Of 34 inpatients on 10/27/14, 6 patients (Patients #6, #7, #8, #9, #10, and #11) were identified as having some degree of risk for falls, but no FALL RISK placard was placed at the patients' doorway.

a) On 10/27/14 at 3:18 p.m., an interview was conducted with Registered Nurse (RN) #3 who stated that upon admission, or at any time a patient was deemed a fall risk, per a nursing assessment, a yellow wristband would be placed on the patient and a yellow FALL RISK placard would be placed in the hallway at the patient's door.

b) On 10/27/14 at 3:30 p.m., an interview was conducted with RN #2 who stated that upon admission or at any time a patient was deemed a fall risk, per a nursing assessment, a yellow wristband would be placed on the patient but no yellow FALL RISK placard was required in the hallway at the patient's door.

c) On 10/27/14 at 3:46 p.m., observation of both units of the facility was conducted with the Chief Clinical Officer (CCO) and the Infection Control Preventionist. Five of 26 patient rooms observed on the units (a total of 6 patients) revealed patients with a yellow wristband, indicating the patient was a fall risk, but no FALL RISK placard or other indicator had been placed in the hallway to identify the patients were at risk for falls.

d) On 10/28/14 at 1:23 p.m., an interview was conducted with RN #1 who stated upon the initial assessment completed by a Registered Nurse, the risk for falls would be assessed and if the patient was deemed a fall risk, a yellow wristband would be placed on the patient and a FALL RISK placard would be placed in the hallway at the patient's door. S/he stated both tasks would be completed by the RN who conducted the assessment. RN #1 stated even a patient at low risk for falls would need to have a FALL RISK placard in the hallway to indicate to all staff, prior to entering the room that the patient was at some risk for falls.

e) On 10/28/14 at 2:06 p.m., an interview was conducted with RN #5 who stated Patient #8, was a "high fall risk" and confirmed there was no FALL RISK placard located in the hallway at the patient's door.

On 10/28/14 at 3:25 p.m., an interview was conducted with RN #5 who stated if a yellow fall risk wristband was placed on a patient, a FALL RISK placard would be placed at the same time. RN #5 stated there was nothing in writing in the facility stating a placard would be placed, but that was part of his/her training at the facility. RN #5 stated "everyone pitches in and makes sure the placard is placed" and no one person was responsible for ensuring a FALL RISK placard would be placed for fall risk patients. RN #5 stated the placard could be placed by a Registered Nurse, a Licensed Practical Nurse, a Certified Nursing Assistant, a therapist, or others. RN #5 stated that at times a FALL RISK placard could go missing after being placed and that it was "everybody's responsibility" to make sure the placards was replaced. When asked how quickly a missing placard would be replaced by staff, RN #5 stated, "hopefully not too long" but could not state a time frame. RN #5 stated FALL RISK placards were needed at patients' doors so that all staff could be aware and ensure that fall prevention measures were in place inside the rooms. RN #5 stated this practice was a "safety thing." RN #5 could not state why there was no FALL RISK placard outside the door of Patient #8, who s/he confirmed was a high fall risk patient.

f) On 10/28/14 at 2:12 p.m., an interview was conducted with RN #4 who stated a yellow wristband and FALL RISK placard would only be placed at the door of patients who scored >51 on the Morse Fall Risk Assessment tool located in the electronic medical record. RN #4 stated registered nurses were responsible for ensuring FALL RISK placards were placed at patients' doors when deemed necessary. RN #4 reviewed the policy and stated it was "not helpful" as a different assessment tool and scale of numbers were found in the policy for implementing fall prevention measures. RN #4 stated RNs were required to know and use the fall prevention policy and the Morse Fall Assessment tool and the two did not match. RN #4 stated there was no written document available to nursing staff to use as a guide for implementing the Morse Assessment tool and that his/her knowledge of using the tool was from the nurse who oriented him/her to the facility.

g) On 10/28/14 at 2:51 p.m., an interview was conducted with the facility's Chief Clinical Officer (CCO) who stated the admitting RN was responsible for determining the fall risk at admission and was also responsible for placing a yellow fall risk wristband and the FALL RISK placard at the patient's door if deemed necessary. The CCO stated this expectation was stated in the facility's fall prevention policy, which s/he reviewed, and was part of orientation for nursing staff. The CCO stated the facility's fall prevention policy did not match the Morse Fall Assessment tool in the electronic medical record, including the parameters stating when a FALL RISK placard would be placed at a patient's door. The CCO acknowledged s/he was not aware of the lack of consistent guidance to nursing staff who were required to use both the electronic assessment tool and the policy. The CCO stated the facility began using the electronic medical record and the Morse Fall Assessment tool approximately two years ago. S/he stated the presence of a FALL Risk placard at patients' doors was not something the facility audited and therefore s/he could not state if this lapse in process posed an increased safety risk to patients.

Based on observations, interviews, and document review, the facility failed to ensure nursing staff consistently scanned patients' identification wristbands, pursuant to facility policy, prior to medication administration.

This failure created a potential safety issue which could lead to medication errors and negative outcomes to patients.

FINDINGS:

POLICY

According to facility policy, Admission of a Patient, the admitting nurse will place the identification bracelet on the patient. The bracelet will be verified with the patient/family/or transfer records for accuracy.

According to facility policy, Medication Administration, prior to administering medications, patients will be positively identified using two forms of identification, e.g. name and medical number found on the patient's wristband.

1. Registered Nursing staff (RNs) did not scan patients' identification wristbands prior to administering medications to patients. RNs, at times, scanned a paper document located away from patients, prior to administering medications, instead of scanning patients' wristbands.

a) On 10/27/14 at 3:18 p.m., an interview was conducted with Registered Nurse (RN) #3 who stated the facility had an electronic scanning system used for medication administration. RN #3 stated, per facility policy and his/her nurse training, a patient's wristband would be scanned prior to administering medications, to confirm the patient's identification, and the medications being administered would also be scanned. RN #3 stated in each patient's room there was also a paper document that contained a bar code which was to be scanned by staff when hourly rounds were conducted. RN #3 stated care providers including technicians, therapists, and nursing staff, were required to scan this document and make a note on the document of the care provided. RN #3 stated RNs would not scan the bar code on the paper document as a means of patient identification prior to administering medications.

b) On 10/27/14 at 3:30 p.m., an interview was conducted with RN #2 who stated prior to administering medications, the patient's wristband would be scanned as a means of of patient identification. RN #2 stated nurses would also ask patients to state their name and date of birth, if able to do so. RN #2 stated the paper document located in each patient room, used to record hourly rounds by members of the multidisciplinary team, should not be used to identify patients prior to medication administration. RN #2 stated scanning the patient's wristband was the facility's policy and was basic nurse training for providing safe medication administration. RN #2 stated the paper document could actually be located "anywhere" including outside the patient's room.

c) On 10/28/14 at 1:23 p.m., an interview was conducted with RN #1 who stated scanning a patient's wristband prior to medication administration was the expectation and was discussed in daily nurse staff meetings.

On 10/29/14 at 8:56 a.m., RN #1 was observed administering medications to Patient #12. Patient #12's hourly rounding sheet was noted and did not have a scanable bar code label. RN #1 stated s/he had observed nurses scan the bar code label on the hourly rounding sheets in the past. S/he stated this was done because over time the wristbands could become "old and hard to scan." S/he stated RNs would scan the paper document instead of requesting a new wristband or reporting bands that could not be scanned. RN #1 stated the inability to scan a patient's wristband was a safety issue and scanning a piece of paper instead of the wristband was not safe as it allowed RNs to avoid getting close to patients and safely identify patients.

d) On 10/28/14 at 2:12 p.m., an interview was conducted with RN #4 who stated it was the facility's policy to scan a patient's wristband, for identification, prior to medication administration but s/he had observed nurses scan the patient's hourly rounding sheet instead of the wristband. RN #4 stated this practice was a "safety issue and was not best practice" because it allowed nurses to scan something that was not on the patient. RN #4 stated the patient's wristband was meant to be the patient identifier and not a piece of paper.

e) On 10/28/14 at 3:46 p.m., an interview was conducted with the facility's Chief Clinical Officer (CCO) who stated prior to administering medications to patients, nurses were trained, per facility policy, to scan the patient wristband for identification purposes. The CCO stated scanning a patient's wristband was safe medication administration practice at it meant nurses were close to patients, looking at patients, and were to also ask patients to state their name and date of birth, if able to do so. The CCO stated the hourly rounding sheet in patients' rooms was not part of the medical record, was used as a patient satisfaction tool, and was not to be used as a scanning substitute for patient's identification wristband.

The CCO stated s/he was unaware that nurses were scanning the paper document to identify patients prior to medication administration. The CCO stated medication administration practices were mainly monitored by pharmacy, including the scanning for patients' identity and ordered medications. The CCO stated observing nurses administer medications was not something that was routinely done by nurse supervisors or nurse leadership. The CCO could not state if the practice of scanning the paper document for identification purposes had contributed to medication errors in the facility because the practice was not known to leadership or to the quality committee.