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Based on observation and medical record review the facility failed to ensure the safety of high fall risk patients, failed to ensure mandatory bed alarms were on, and failed to ensure safe monitoring after administration of a sedative (A144), failed to ensure the use of restraint or seclusion was in accordance with physician's order (A168), failed to ensure there was a physician order for the use of bed rail restraints (A170) and failed to notify CMS of a patient death associated with the use of restraints.(A213) The cumulative effect of this systemic practice resulted in a risk to the health and safety of all facility patients.

Based on review of medical records, observation and staff interview the facility failed to ensure the safety of high fall risk patients, failed to ensure mandatory bed alarms were on and risk assessments were completed timely, and failed to ensure safe fall monitoring after administration of a sedative. This affected four of five high fall risk patients reviewed (Patient #2, #3, #4 and #6). The census at the time of the survey was 112.

Findings include:

Review of the facility policy titled "CP-1-Falls Prevention (Adult Inpatient), last reviewed 03/2014, revealed all
patients are assessed on admission and every shift using a fall risk assessment tool to determine the risk for falls. A flagging system is used to alert hospital staff to patients at risk for falls. The falls assessment and falls prevention plan is documented in the patient's medical record by the registered nurse (RN). The Fall Risk Assessment wheel revealed the red area as "High falls risk with high injury risk" with mandatory interventions which included appropriate alarms.
Patient and family are to be educated of the Fall Risk Protocol, provided falls prevention educational handouts and the RN is to document that educational materials were provided.

1. Observation on 02/20/18 from 10:28 AM through 10:32 AM revealed the red high fall risk wheel was observed on the door frame for Patient #2, #3 and #4. All three patients were in bed and bed alarms were off.

Review of medical records revealed on 02/20/18, Patient #2, #3 and #4 were documented as High Fall Risk with risk of injury with no documented evidence of bed alarms on or monitored.

Staff D stated on 02/20/18 at 10:34 AM the red and orange fall risk wheel is an indicator bed alarms should be on and confirmed the alarms were off for Patient #2, #3 and #4.

On 02/20/18 at 10:40 AM per interview, Staff D stated the RN will do a patient fall evaluation and if the bed alarm can be off then will instruct the family regarding the fall protocol and tell the family not to leave the room without telling the RN.

On 02/20/18 at 10:43 AM per interview, the family of Patient #4 stated they were not aware of the bed alarm or not to leave the room without telling the nurse. The patient also stated he/she was not aware of the bed alarm.

On 02/22/18 at 10:38 AM per interview, Staff H reviewed the medical record for Patient #4 and was unable to provide documented evidence of patient/family education on fall risks protocol or that preventative educational handouts had been given.

2. Review of the medical record for Patient #3 revealed admission 02/19/18 with a High Fall Risk. A re-assessment for fall risks was done on 02/20/18 at 8:00 AM, the next fall risk assessment was done 02/21/18 at 4:27 AM (20 hours and 27 minutes later).

On 02/21/18 at 3:33 PM per interview Staff A and Staff C both confirmed 20 hours between risk assessments is not acceptable. Staff A stated the risk assessments should be done at the beginning of each 12 hour shift.

3. Review of medical record for Patient #6 revealed an 80 year old, admitted 02/14/18, with a fall during hospitalization. The patient was agitated, confused, has dementia, is impulsive with unsteady gait.

Review of the "A+I-Adult" assessment revealed on 02/14/18 Patient #6 was "high fall risk with low injury risk".

Review of "Admission Risk Screen", dated 02/14/18, revealed Patient #6 was to have supervised toileting and bed/chair alarms (mandatory for all high risk patients).

On 02/18/18 at 4:01 PM patient was agitated and yelling, an order for Ativan (sedative) was obtained.

On 02/18/18 at 9:00 PM Patient #6 is confused and disoriented to time, place and situation and was documented as high fall risk with low injury risk.

Review of the Clinical Event Note, dated 02/19/18 at 2:05 AM, revealed Patient #6 was laying on the window seat bench prior to being found on floor next to it. Patient got up to go to bathroom, lost balance and fell. Patient has unsteady gait.

Review of the RN communication note, dated 02/19/18 at 2:00 AM, revealed Patient #6 rolled off sofa to floor.

On 02/22/18 at 2:38 PM per interview, Staff A, B and C all confirmed the hourly safety checks, bed alarm and fall protocol for this high fall risk patient was not done prior to Patient #6's fall.

Based on medical record review and staff interview, the facility failed to ensure the use of restraint or seclusion was in accordance with physician's order. This affected two of three medical records reviewed for use of restraints, Patients' #9 and #10. The census at the time of the survey was 112.

Findings include:

1. The medical record of Patient #9 was reviewed on 02/22/18 at 1:40 PM with Staff H. Review revealed a 02/21/18 12:11 PM physician's order for "restraints, violent or self-destructive, age over 18 - both arms/hands."

Review of the corresponding nursing restraint documentation revealed between 11:55 AM and 1:15 PM on 02/21/18, Patient #9 was in "locked restraints" on "both arms/hands, both legs."

Staff H confirmed this finding and confirmed there was no order for the use of leg restraints.

2. The medical record of Patient #10 was reviewed on 02/22/18 at 1:44 PM with Staff H. Review revealed a 12/28/17 8:00 AM physician's order for "restraints, non violent or non self-destructive - both arms/hands, wrist/soft restraints."

Review of the corresponding nursing restraint documentation revealed between 8:00 AM and 8:00 PM on 12/28/17, Patient #10 was in "soft extremity" restraints on "both arms/hands" and "right leg."

Staff H confirmed this finding and confirmed there was no order for the use of the right leg restraint.

Based on observation and medical record review, the facility failed to ensure there was a physician order for the use of restraints on four of four patients observed in Rooms 401, 616, 617 and 619 with all four bed rails up. The census at the time of the survey was 112.

Findings include:

Tour of the 6th floor was conducted on 02/20/18 beginning at 9:45 AM. While touring, the patients in rooms 616, 617 and 619 were observed to have all four bed rails up while lying in bed. Staff A confirmed these observations at that time. Staff A was asked if four bed rails was considered a restraint and replied yes.

At 10:10 AM after speaking with the floor RN and checking the electronic medical record of those patients in rooms 616, 617 and 619, Staff A confirmed there was no physician's order for the use of restraints (in this case four bed rails).

Tour of the 4th floor was conducted on 02/20/18 beginning at 10:15 AM. While touring, the patient in room 401 was observed to have all four bed rails up while lying in bed. Staff A confirmed this observation at that time.

At 10:36 AM after speaking with the floor RN and checking the electronic medical record of the patient in room 401, Staff A confirmed there was no physician's order for the use of restraints (in this case four bed rails).

Based on medical record review and staff interview, the facility failed to notify CMS of a patient death associated with the use of restraints. This affected one of 17 patient deaths associated with the use of restraints, Patient #10. The census at the time of the survey was 112.

Findings include:

On 02/22/18 at 9:12 AM Staff K was interviewed regarding the process for reviewing restraint associated deaths. At that time, Staff K confirmed there were 17 such deaths in the past six (6) months and that none required reporting to CMS based on the criteria.

Patient #10's medical record was then reviewed and revealed he was restrained at the time of his death with bilateral soft wrist restraints and a right leg restraint.

Staff K confirmed this finding on 02/22/18 at 1:54 PM. At that time Staff K also confirmed Patient #10's death was not reported to CMS.

Based on observation and medical record review the facility failed to ensure nursing care was provided as ordered for the prevention of wounds. (A392) The cumulative effect of this systemic practice resulted in a risk to the health and safety of all facility patients.

Based on medical record review and staff interviews, the facility failed to ensure nursing care was provided as ordered for Patient #1 who developed coccyx wounds. The census a the time of the survey was 112.

Findings include:

1. Patient #1 was re-admitted to the facility the afternoon of 01/06/18 for Mental Status Change. Review of Patient #1's medical record revealed at the time of her discharge on 01/06/18 her skin was intact. After being re-admitted to the facility later on 01/06/18 her skin was still intact.

On 01/07/18 at 5:34 PM the RN entered orders for hygiene care, assist with ADL's during waking and sleeping hours, heel elevation, therapeutic mattress and turning/repositioning every two hours.

Skin Assessments were completed once per shift between 01/07/18 and 01/20/18. Patient #1 was noted to have bruises on her face, arms, right hip and abdomen initially. The bruises were related to her previous fall on 01/05/18.

Review of Pressure Ulcer Prevention (positioning) and Activity (activity type) was reviewed for evidence it was conducted every two hours (or four hours while asleep) as per order. The following concerns were identified beginning on 01/07/18:

Between 12:00 AM and 7:59 AM there was no documented evidence of repositioning or activity, a period of eight hours. At 10:00 AM staff documented Patient #1 refused turning but did not offer repositioning or activity again until 2:00 PM. Patient #1 returned from hemodialysis at 5:45 PM but there was no documented evidence of repositioning or activity until 2:05 AM on 01/08/18, approximately eight and one half hours later.

On 01/09/18 at 4:33 PM staff assisted Patient #1 to reposition but then not again until 8:51 AM on 01/10/18, approximately 16 hours later. After returning from hemodialysis, staff documented Patient #1 was assisted with repositioning at 3:00 PM on 01/10/18 then not again until 7:37 AM on 01/11/18, approximately 16 hours later.

On 01/12/18 at 3:00 AM staff documented Patient #1 repositioned independently but there was no documented positioning or activity again until 12:00 AM on 01/13/18, 21 hours later. Patient #1 was then repositioned every one to two hours per documentation.

A Braden Risk Assessment completed on 01/13/18 at 8:15 PM revealed Patient #1 now had a "wound" on her "coccyx." Braden Risk Assessments were completed at least every two days, per policy. A wound assessment was not completed until 8:15 PM, at which time the RN documented the wound was within defined limits, open to air with redness on the periwound area.

On 01/14/18 at 8:12 PM, approximately 24 hours from the first documented wound assessment, the RN completed another wound assessment and documented the wound type as "skin tear; DTI" (deep tissue injury). The next documented wound assessment was not until 01/15/18 at 8:00 PM (24 hours later), at which time the RN described the wound as an "ulceration" and revealed a "foam" dressing was applied.

A Wound Care Consult was not completed until 01/17/18 at 5:06 PM, approximately four days after the "coccyx wound" was first identified. At that time the Wound Care RN identified three distinct coccyx wounds: a left coccyx wound measuring 3.2 cm x 3 cm x depth undetermined; a right coccyx wound measuring 5 cm x 4 cm x depth undetermined; and a medial coccyx wound measuring 1 cm x 1.2 cm x depth undetermined.

The left coccyx wound was a deep tissue injury with denuded skin, loose purple tissue and serous drainage. The right coccyx wound was a deep tissue injury with denuded areas, loose purple tissue and serous drainage. The medial coccyx wound was an unstageable pressure injury with 100% yellow slough ad serous drainage. All three wounds required packing.

Patient #1 was discharged to a skilled nursing facility on 01/20/18 with said wounds.

Staff H was made aware and confirmed the above findings on 02/22/18 at 12:34 PM.










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