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Based on review of hospital policies and procedures, medical record review, fall incidents, and staff and physician interviews, the nursing staff failed to supervise and evaluate the delivery of patient care as evidenced by failing to assess patients following a fall per policy and failing to notify the physician of a change in a patient's status for 3 of 5 sampled patients that fell (#5, #12, and #14).

The findings include:

Review of the hospital's policy "Altered Mental Status", revised 07/28/2010, revealed "... Scope: General: 2c. Initial and frequent vital signs and neurological checks will be obtained and recorded as appropriate to the patient's mental status...".

Review of the hospital's policy "Fall Risk Assessment", revised 07/28/2010, states..."3. The Fall Risk Assessment includes the following questions. Yes to any of these statements places the patient at Fall risk. a. History of recent falls b. Poor Mobility or Generalized Weakness c. Confusion or Disorientation... 4. When a fall risk is determined the following prevention measures shall be initiated as applicable to the patient needs. A yellow arm bracelet should be placed on any fall risk patient. a. Placement of a yellow "fall risk" arm band b. Bed low/wheels locked c. Call bell within reach d. Side rails up e. Family Present f. Frequent Observation/Assessment... 6. The following process is to be implemented if a patient fall should occur: a. Initiate the Post Fall Huddle form (located on the infoweb) by the involved care team members to try to determine why the fall occurred, to initiate interventions to prevent future falls, to modify the plan of care, ect., including communications with patient/family for additional insight and/or suggestions."

Review of the hospital's policy entitled "Head Injuries", reviewed 08/02/2010, revealed "Purpose: To establish a standard of care for patients experiencing head injuries. ...6. Notify physician and assess for other injuries. 7. Obtain and record vital signs and neurological status as per Glasgow Coma Scale (neurological assessment)..."

1. Closed record review of Patient #5 revealed an 84 year old male admitted to the hospital on 10/10/2010 and discharged 10/15/2010. The final discharge diagnoses on 10/15/2010 were severe anemia secondary to GI bleed, severe dementia, pneumonia, and severe erosive esophagitis. Review of records revealed the patient was readmitted on 10/22/2010. Closed record review of Patient #5 revealed the patient was sent via ambulance (EMS) by the family to the ED (emergency department) with increased confusion on 10/22/2010 arriving at 2350. Record review revealed at 2352 on 10/22/2010 a Fall Risk Assessment was completed and identified the patient as a fall risk and "fall precautions have been initiated". Record review revealed fall precautions implemented included: yellow "fall risk" arm band was placed on patient; falling star was placed on door; bed placed in low position with wheels securely locked; call bell was within reach; and two side rails were up. Triage Assessment at 2353 on 10/22/10 indicated the patient "is awake, confused, oriented to person, place". Further review of Patient #5's ED record showed the physician documented at 0206 on 10/23/2010 "ED course: patient found on floor hit head, abrasion to right temple, will repeat CT". Review revealed no other documentation to show the physician re-examined the patient or conducted any neurological tests. Further record review revealed a repeat head CT was performed on 10/23/2010 at 0209 (after the fall from the stretcher). Review of the head CT results revealed, "Impression: No acute intracranial hemorrhage or skull fractures." Further record review showed the nurse documented at 0231 and again at 0430 "awake; alert ; oriented to person" no pupil checks were documented, vital signs were within normal range. Record review revealed the nurse documented on 10/23/2010 at 0713 (5 hours and 7 minutes after the fall) "level of consciousness is drowsy" again with no pupil checks documented, vital signs at 0712 were within normal range. At 0906 the nurse again documented patient"awake, alert confused, oriented to person with no pupil checks being documented, vital signs at 0908 were with-in normal range. At 1055 "level of consciousness confused, speech is slurred and pupils are 1mm, sluggish", vital signs were again with-in normal range. Record review revealed no documentation that the physician or charge nurse were notified of a change in the patient's condition/neurological exam. Record review revealed no documentation of further assessment of the patient by the physician. Review of the nurse's notes revealed no documentation of a post fall assessment or neurological checks including a Glasgow coma score after the patient fell and hit his head on the floor. Record review revealed the patient was discharged to home at 1101 on 10/23/2010, with a discharge diagnosis of "Impression: Fall; confusion; Pneumonia; Concussion without LOC (loss of Consciousness) ". Record review revealed no family member presented to the ED until the time of discharge.

Interview on 12/15/2010 at 0900 with the hospital's CNO (Chief Nursing Officer) confirmed there was no documentation available that a post-fall assessment or neurological checks including a Glasgow coma score had been conducted by the nurse or physician after Patient #5 fell in the ED. Interview further revealed, "This is deficient nursing practice ....It is hospital policy to obtain and record vital signs and neurological status as per the Glasgow coma scale."

Review of the "Post Fall Assessment" huddle form, not dated and not signed by any employee, revealed factors contributing to the fall were "confusion/memory impaired and side-rails 2 / 1 broken".

Review of a report of the incident dated and signed on 10/23/2010 revealed the fall took place at 0210 on 10/23/2010. Review of this report also revealed the "side-rail was broken and won't latch in place".

Review of a written statement by Registered Nurse (RN) #1 (the nurse assigned to patient #5 when he fell) revealed " ...he was confused...I was at the nurse's station and heard a noise come from his room. I immediately went to check on him and I found the pt. laying on the floor to the left side of the bed... several nurses and the doctor came in and we were able to get him back in the bed....Both side-rails were put up and (employee's name) came to take him back to CT: While (name of employee) was pushing the stretcher down the hallway the same side-rail came down again by itself that contributed to his fall and (name of employee) had to put the side-rail up again.... When the pt. came back from CT I checked his vitals since there wasn't enough time before he was taken to CT ...We put him in a different stretcher just to be sure the side-rails wouldn't fall down again."

Interview with the Director of Facilities on 12/15/2010 at 0930 revealed all stretchers have preventive maintenance (PM) on a yearly schedule. The stretcher involved in this incident had PM performed on 12/08/2009. Per the Director of Facilities the side rail may have broken as a result of the patient trying to climb over the rail. Interview revealed a sign was been placed on the stretcher on 10/23/2010, stating in bold letters "WARNING inoperative equipment DO NO USE" and written on the sign (right) side rail broken latch doesn't stay locked. Interview revealed this particular stretcher was been repaired on 10/28/2010.

Telephone interview with RN (registered nurse) #1 on 12/15/2010 at 1135 revealed the nurse cared for Patient #5 on 10/22/2010 and 10/23/2010. Interview revealed, "I was at the nurse's station and heard something coming from his room. I went in and found him lying on the floor on the left side of the stretcher. He was on his right side. He had a laceration on his forehead. I did not check his vital signs before he went to get another CT (computed tomography scan) and I can't remember when I took them. I didn't chart what I needed to chart. I didn't do neuro checks and they should have been done". Interview revealed that assessing a patient's neurological status including Glasgow coma scale after a head injury is standard nursing practice. Interview further revealed the hospital's policy for post-falls assessment was not followed.

Telephone interview with RN #2 on 12/15/2010 at 1140 revealed the nurse cared for Patient #5 on 10/23/2010 and assessed Patient #5 prior to discharge. Interview revealed "he was sleepy and drowsy. At 1055 his speech was slurred and his pupils were sluggish. I should have reported this (change in condition) to the physician".

Interview with an ED physician on 12/15/2010 at 1230 revealed the physician was working in the ED on 10/23/2010 when Patient #5 was discharged to home. Interview revealed "I was not informed of these changes. If I had been told about his slurred speech and sluggish pupils, I would have re-evaluated the patient."

Phone interview with the charge nurse on 12/15/2010 at 1245 revealed she had not been made aware of the possible change in the patient's pupil response.

Phone interview with a family member on 12/15/2010 at 1038 revealed that on the morning of 10/24/2010 (1 day after discharge), uncertain of time, the patient was found dead. No autopsy had been performed.

Phone interview with the Montgomery Medical examiner on 12/15/2010 at 1055 revealed after review of the medical data sent to him it was concluded that death was unlikely due to the head trauma, based on the negative CT scan, thus he felt an autopsy was not needed.

2. Closed record review of patient #12, a 84 year old male, revealed the patient was brought to the ED (emergency department) via a wheelchair by the patient's son on 10/17/2010 at 1411, because "...patient is falling frequently and acting inappropriately. reports that pt. is unsteady on feet. reports abrasion on left elbow from falling..." Record review revealed documentation at 1417 of a Fall risk assessment that identified the patient as a fall risk and "fall precautions have been initiated. Yellow 'fall risk' arm band placed on patient. Falling star place on door. Bed in low position with wheels securely locked. Call bell within reach. Side rails up X 2. Family Present and informed to notify staff if they need to leave the bedside." Review of nursing documentation at 2025 on 10/17/2010 revealed "scream heard coming from pt's room. upon entering pt's room, pt was lying on his back on the floor with his daughter at his side. pt's daughter reports that pt fell and hit his head on the door. I did not witness fall. pt assisted up and back onto stretcher by security personnel..." Record review revealed at 2056 on 10/17/2010 the patient had a CT of head, which showed no evidence of brain edema, infarct, mass or intracranial hemorrhage. Record review revealed at 2224 on 10/17/2010, the physician wrote an order to admit the patient. Record review revealed no documentation of neurological assessments including a Glasgow coma scale by the nurse or the physician.

Review of a Post Fall Assessment form "huddle" undated and not signed revealed the contributing factors to the fall were: Need to void - (pt with Foley) and change in mental status/behavior.

Interview with the Hospital's CNO (Chief Nursing Officer) at 1305 on 12/15/2010 revealed the CNO reviewed the patient's medical record. Interview revealed there was no documented evidence that neurological exams were completed by the nurse or the physician. Interview revealed neurological assessments including a Glasgow coma scale should have been done because it was standard nursing practice. Interview revealed hospital policies were not followed.



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3. Closed record review of Patient #14 revealed a 37 year-old admitted 09/10/2010 with psychotic behavior, including self-injurious behavior. Review of an incident report completed by a registered nurse, dated 09/14/2010 at 2340, revealed Patient #14 "was sitting at desk in room, got up to go to bathroom and fell. Pt (patient) states he hit his head and his R (right) leg is numb. VS (vital signs) are 134/78, HR (heart rate) 71, 02 (oxygen) 99%. (Name of doctor) notified of fall. Dr. ordered consult from hospitalist...". Review of the patient assessments revealed no documentation that the nurses performed a neurological assessment, including a Glasgow coma score after the fall.

Interview on 12/15/2010 at 1330 with the director of the behavioral health unit revealed "this patient should have had neuro checks performed which is just good nursing practice". Interview confirmed there was no available documentation that the nursing staff performed neurological assessments after the patient fell and hit his head. Interview revealed the nurse failed to follow the hospital's policy for post-fall assessments.



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