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Based on facility document review, policy review, medical record review and interview the facility failed to ensure care was provided in a safe setting for 4 of 6(Patient #2, #3, #4 and #5) who sustained falls with injuries.

The finding include:

1. Patient #2 had 2 falls in the facility on 12/13/2022 and 12/15/2022. Patient #2 fell into the wall on 12/15/2022 with note skin teals to the left elbow and the left knee. patient was placed on neuro checks and was found with no heartbeat at 10:50 PM the night of the fall. There was no Team Interdisciplinary Team Occurrence report documented.

Patient #3 had the following falls:
(a) 1/16/23 at 12:15 AM - Laceration head, abrasion right shoulder, skin tear right hand with injury.
(b) 1/17/23 at 6:45 AM - Laceration back of head - fall with injury
(c) 1/21/23 at 2:29 PM fall with no injury
(d) 1/22/23 at 5:45 AM - Laceration back of head - fall with injury
(e) 1/24/23 at 3:00 PM - Bleeding from head/previous suture site - with injury
(f) 1/28/2023 fell out of wheelchair while being transported by staff - without injury
(g) 2/5/23 at 8:55 AM - Hematoma/sm [small] laceration right eye brow.

There was no Team Interdisciplinary Team Occurrence report documented.

3. Patient #4 had the following falls:
(a) 11/22/2022 - Hematoma to the forehead
(b) 12/3/2022 - Laceration to Left eyebrow, skin tear to 1st/2nd knuckle area, and skin tear to lateral side of hand below pinky

There was no Team Interdisciplinary Team Occurrence report documented.

4. Patient #5 had the following falls:
(a) 1/22/23 at 10:00 PM -Bruising back of head
(b) 1/26/23 at 7:05 AM - Hematoma back of head
(c) 1/26/23 at 3:30 PM - Fracture left hip

There was no Team Interdisciplinary Team Occurrence report documented.

5. Patient #6 had a fall without injury on 1/9/2023.

There was no Team Interdisciplinary Team Occurrence report documented.

6. Patient #7 had a fall without injury on 10/3/2022 and 10/8/2022.

There was no Team Interdisciplinary Team Occurrence report documented

In review of the Interdisciplinary Team Occurrence Report on 10/8/2022 at 7:22 PM revealed an incomplete report.

Refer to A 144

Based on document review, medical record review, and interview the hospital failed to ensure patients received care in a safe setting for for 4 of 6(Patient #2, #3, #4, #5) patients who sustained a fall with injury while being care for by hospital staff and failed to document occurrence reports or complete the form in it's entirety.

The findings include:


1. Review of the facility's "Fall Prevention Program" policy with a revised date of "8/2019" revealed, "...The intent of...fall prevention program is to increase patient safety and provide a coordinated system to identity patients at risk and develop an individualized interdisciplinary plan of care to minimize the incidence of falls and subsequent injury...Direct the creation of an individualized treatment plan to reduce fall risk. Monitor and evaluate patient outcomes...Completes post occurrence analysis report of al fall related occurrences...Ensures treatment plan reflects individual goal and interventions. Collect data specific to patient falls...Ensures procedures for high risk patients are in use. Completes nurse event note on all fall-related occurrences and initiates interventions to avoid reoccurrence of event...Reviews all Nurse Event Notes..Follows safety interventions for at risk patients...Report any risk factors identified...Conducts balance and mobility assessments as needed...Notifies nursing staff of patients with risk taking behaviors...Assesses mobility and orders interventions such as physician therapy consultation...Supports a safe environment of care...preventative maintenance, environmental checks..."

2. Medical record review revealed that Patient #2 was admitted on 12/13/2022 with a diagnosis of Alzheimer's Disease.

Review on 12/13/2023 of the Morse Fall Scale (to identify risk factors for falls in hospitalized patients) revealed a total score of 105 (46 and higher =High Risk).

Review of the nursing flowsheet on 12/13/2023 at 8:00 PM revealed, "...fall with no injury..."

Review of Patient #2 did not reveal a new Morse Fall Scale documented for the fall on 12/13/2022.

Review of the "Falls with Injury" report from 10/2/23 - 2/14/2023 did not reveal a fall with injury for Patient #2. On 12/15/2022 Patient #2 had skin tear to left elbow and 2 abrasions to his left knee and was placed on neuro checks.

Review of the individual nursing progress notes on 12/15/2022 at 8:00 AM revealed, "...Patient has no c/o [complaint] pain r/t [related to] previous fall. Patient ST [skin tear] to Left fore arm is clean dry, Steri strips intact...12:43 PM...Patient was observed standing up on his own and MHT [Mental Behavior Tech] went around the foot of the bed to assist patient back into bed. At that time patient fell forward into the wall. Patient assessed head to toe. Patient noted to have a ST [skin tear] to Left elbow. and 2 abrasions to his Left knee. Patient was yelling out at staff to leave him alone. Patient assisted back into bed x [times] 3 staff...7:15 PM...neuro checks are still in progress....8:30 PM...Pt [patient] resting with eyes closed, no agitation noted...10:50 PM Staff in to transfer pt to bed; noted unresponsive and notified signee. Pt [Patient] noted with no heartbeat 2 minutes and no breath sounds. TOD [Time of Death] 10:45 PM. DON [Director of Nurse notified of death in facility..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the two falls. on 12/13/22 and 12/15/22.

Review of Patient #2's diagnosis revealed, "...Primary Diagnosis Alzheimer's Disease, Major Depressive Disorder, Anxiety Disorder, Hyperlipidemia, Pain, and Degenerative Nervous System Disorder..."

In an e-mail correspondence on 2/1/2023 at the Administrator was asked for a list of deaths in the building from October to Present. The Administrator stated, "...We had one death, December 15,2022. His name was Patient #2..."

In an e-mail correspondence on 2/17/2023 the Administrator stated, "...His (Patient #1) condition was guarded on admission and he also had terminal agitation..." The Diagnosis documented in Patient #2's chart to this surveyor upon a e-mail request on 3/7/2023 at 3:38 PM did not reveal a diagnosis of Terminal Agitation.

3. Medical record review on 1/14/2023 revealed that Patient #3 was admitted with a diagnosis of Dementia, with Psychotic Disturbance.

Review on 1/14/2023 of the Morse Scale (to identify risk factors for falls in hospitalized patients) revealed a total score of 80 (46 and higher=High Risk).

Review of the skin assessment on 1/14/2023 at 4:26 PM revealed, "...1 residual staple to back of head (reportedly had 6 staples to head on 1/3/23 from previous head injury).

Review of physician's orders on 1/14/2023 revealed a medication order for Eliquis 5 mg [milligram] oral tablet 1 tablet twice a day for deep vein thrombosis.

Review of the "Falls with Injury" report from 10/2/22 - 2/14/23 revealed that Patient #3 had the following falls:
(a) 1/16/23 at 12:15 AM - Laceration head, abrasion right shoulder, skin tear right hand with injury.
(b) 1/17/23 at 6:45 AM - Laceration back of head - fall with injury
(c) 1/19/23 at 7:10 AM - Laceration to scalp and finger lacerations
(d) 1/21/23 at 2:29 PM fall with no injury
(e) 1/22/23 at 5:45 AM - Laceration back of head - fall with injury
(f) 1/24/23 at 3:00 PM - Bleeding from head/previous suture site - with injury
(g) 1/28/2023 fell out of wheelchair while being transported by staff - without injury
(h) 2/5/23 at 8:55 AM - Hematoma/sm [small] laceration right eye brow.

This fall was not listed on the "Falls with Injury" report but was listed on the Emergency Room [ER]Transfer report on 1/19/2023 at 7:10 AM brought to the ER for scalp laceration 2 cm [centimeter] and 3 staples and finger lacerations 2 cm with 2 stitches.

Review of the nursing progress notes on 1/16/2023 at 12:15 AM Pt [patient] fell in hallway. When asked what happened pt [patient] stated. "I was going to the kitchen"...Laceration x [times] 2 noted to top of head, skin tear to right wrist, laceration to back of right ear, and abrasion to right shoulder top edge noted...4:00 AM revealed, "...Pt just returned from ER [Emergency Room]...11 staples noted to top of head..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/16/2023.

Review of the nursing progress notes on 1/17/2023 at 11:30 AM revealed, "...Pt just returned from the ER [Emergency Room] after falling in the dining room. Pt [patient] has 5 staples to the back of his head..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/17/2023.

Review of the nursing flowsheet on 1/18/2023 at 8:00 AM revealed, "...Observation Status Q [every] 15 minute checks...fall 1/17/23 sent to ER [Emergency Room]; received staple to head lac [laceration]...Pt [patient] is unsafe with transfers and ambulation, requires w/c [wheelchair] for mobility..."

Review of the nursing flowsheet on 1/19/2023 at 10:44 PM revealed, "...Observation Status Q [every] 15 minute checks...Fall,injury, or Other in the past 72 hours (fell in AM of 1/19/22) fall with injury to right side of frontal head occurring this AM...Continues to get out of bed and go walking down the hallway alone. Pt [patient] has fallen multiple times with injury to head. Pt [patient] unsteady on his feet alone..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/19/2023.

Review of PT [Physical Therapy] on 1/19/2023 Screen revealed, "...Onset Date: 1/17/2023...Referral Source: fall screen: falls 1/17 and 1/19.

Review of PT [Physical Therapy] on 1/19/2023 Screen revealed, "...Onset Date: 1/17/2023...Referral Source: fall screen: falls 1/17 and 1/19. Ambulation Assisted...Safety Comments: no safety awareness, resistant to redirection: Restraints: Present...Restraints Comments: body alarm...Recommendations: Physical Therapy Not indicated at this time...If PT [Physical Therapy] no indicated, document reason: will rescreen once pt. following commands and decrease in resistance to safety...Additional Comments: Pt. referred to PT @ [at]...3 more falls. Pt. returning from ED [Emergency Department] after fall this AM. Pt. is not a good candidate for PT at this time 2...having no safety awareness and being resistant to redirection and being combative..." There are no client doctor orders for this.

Review of the client doctor orders on 1/22/2023 at 12:09 AM revealed an order for Physical Therapy with a start time and date of 1/22/2023 at 12:08 AM and a stop date and time of 1/29/2023 at 12:09 AM. The following are a sample of the physical therapy notes from 1/19/2023 through 2/13/2023.

Review of the nursing progress notes on 1/21/2023 at 2:39 PM revealed, "...Had observed fall from rock-n-go at approx [approximately] 1130 [11:30 AM] in dining room, slid from w/c [wheelchair] trying to pick up something from the floor. No injury..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/21/2023.

Review of the nursing progress notes on 1/22/2023 at 6:31 AM revealed, "...Received a call the patient had another fall, hit his head...12:16 AM..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/22/2023.

Review of the nursing progress notes on 1/24/2023 at 7:30 AM revealed, "...Patient has not complained of pain or discomfort related to his fall on 1/23/2024 [2023]...3:00 PM Patient found sitting on his but in the dining room at 3:00 PM. Patient found with some blood running from his stitches placed on the frontal part of his head..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/24/2023.

Review of the Physical Therapist note on 1/30/2023 at 2:10 PM revealed, "...Pt. [patient] had another fall 01/28 when he slide out of w/c [wheelchair] when being transported by staff..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/28/2023.

Review of the nursing progress note on 2/5/2023 revealed, "...patient had fallen forward out of his wheelchair...Patient was observed by this nurse on his hands and knees when entering the dining room...Patient sent to [Named Hospital] #1..."

4. Medical Record Review on 11/19/2022 revealed that Patient #4 was admitted with the following diagnosis Unspecified Dementia, with Agitation.

Review of the nursing flowsheet on 11/22/2022 at 7:40 PM revealed, "...Fall at 8:20 PM, 11/22/22 in dining area. Unwitnessed with hematoma to forehead..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/22/2023.

Review of the client doctor orders on 11/23/2022 revealed an order for physical therapy related to valuate and treat post fall (PM of 11/22/22).

Review of the individual nursing progress note on 11/23/2022 at 7:55 PM revealed, "...Skin Comments: hematoma - center L [left] forehead,,,above L [left] eyebrow - sutures removed..., or Other in the past 72 hours...No (had a fall on 11/22/2022)..."

Review of the individual nursing progress note on 11/24/2022 at 8:46 AM revealed, "...Skin Comments: right eyebrow laceration - open to air...Fall, Injury, or Other in the past 72 hours?: No (had a fall on 11/22/2022)..."

Review of the nursing progress note on 12/3/2022 at 7:00 PM revealed, "...Patient had a fall (witnessed by MHT) in hallway. Apparent injuries include approximately 1.5 inch laceration to left eyebrow, skin tear to 1st/2nd digit knuckle area, and a small skin tear to lateral side of hand below pinky. Pressure applied to left eyebrow laceration and gauze dressing applied; steri strips applied to left hand...7:20 PM...EMS [Emergency Medical Service] assisted onto stretcher and transferred to Tennova ER [Emergency Room]..."

Review of the individual nursing progress note on 12/3/2022 at 1:10 PM revealed, "...Patient transfers back to this facility from ER [Emergency Room]. Patient brought to her room via wheelchair. Injury sustained above left eyebrow closed with sutures.

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 12/3/2022.

Review of the independent nursing note on 12/5/2022 at 8:55 PM revealed, "...She had a witnessed fall in hall on 12/3/2022 and received a laceration above her left eyebrow that required a trip to the ER [Emergency Room] and three sutures to close..."

Review of the nursing progress note on 12/7/2022 at 11:00 AM revealed, "...closed laceration to right eyebrow open to air...closed laceration to left eyebrow closed with sutures..."

5. Medical Record Review revealed that Patient #5 was admitted on 1/18/2023 with an admitting diagnosis of Alzheimer's Disease.

Review of the "Fall with Injury" report on 10/2/22 thru 2/14/22 revealed that Patient #5 had the following falls:
(a) 1/22/23 at 10:00 PM -Bruising back of head
(b) 1/26/23 at 7:05 AM - Hematoma back of head
(c) 1/26/23 at 3:30 PM - Fracture left hip

Review of individual progress nursing note on 1/23/2023 at 3:35 AM revealed, "...resting in bed at this time. Neuro checks continue s [status]/p [post] fall in her room earlier in shift..." This note was not electronically signed until 1/25/2023 at 8:39 PM.

Review of individual progress nursing note on 1/23/2023 at 9:15 AM revealed, "...Patient reportly had a fall last night and required PRn's [as needed medications] for behaviors, last dose being Haldol/benadryl at 3:00 AM..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/22/2023.

Review of individual progress nursing note on 1/26/2023 at 8:00 AM revealed, "...Patient had a fall this morning around 7:00 AM and has a hematoma on the back of her head will monitor..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/26/2023.

Review of individual progress nursing note on 1/26/2023 at 3:30 PM revealed, "...Notified by med nurse that patient was in the floor. Patient was observed laying on her right side in the door way of the bathroom and appears to have been returning from the bathroom when the fall occurred. Patient was wet. Patient was assessed, no apparent injuries but did however c/o [complain] to her left hip when staff began changing her in the bed. Patient c/o [complain] with movement and does not move it independently when asked. Patient does not report pain if it is not being touched or moved. Legs appear to be even. Physician #1 made aware at 3:42 PM, Xray of Left hip ordered. Patient's husband made aware at 4:00 PM. Patient has clip alarm while in bed and while seated as intervention. Patient currently in bed with clip alarm in proper working order..."

Review of the Interdisciplinary Team Occurrence Investigation Worksheet revealed the date/time of incident was 1/26/23 at 3:30 PM, "...The incident was unwitnessed...resulted in a Left femoral fx [fracture]...Patient had surgery on 1/31/2023 for repair of left femoral fracture. Plan was to apply pull alarm to alert staff when she attempted to get up unassisted...Morse Fall Scale Risk Score was a High Risk..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/26/2023.

Review of the Named Hospital #1 Emergency Room notes on 1/27/2023 at 10:43 PM revealed, "...Fall x [times] 2 yesterday, left hip fracture hit head yesterday hematoma...according to the records she had been running from the nurse when she fell...x-ray at facility showed a probable hip fracture...Fall close fracture...Basicervical fracture with impaction and displacement to the left femoral neck...Patient will be admitted for surgery..."

6. Medical record review on 1/8/2023 revealed that Patient #6 was admitted with the following diagnosis Alzheimer's Disease.

Review on 1/9/2023 of the Morse Fall Scale (to identify risk factors for falls in hospitalized patients) revealed a score of 80 which is high risk (High Risk =46 and higher).

Review of the nursing shift assessment on 1/9/2023 at 9:35 revealed, "...Pt [patient] was participating in activities in the activity room and as she was walking back to her chair, she lost her balance and fell onto the floor...Injury...none noted..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/9/2023.

Review of the independent nursing note on 1/11/2023 at 8:27 AM revealed, "...Pt fell in the dining room...Pt [patient] demanded to go to the ER [Emergency Room]...Pt [Patient] did not hit her head. Pt did not lose consciousness. Pt skin was assessed. A redness was noted on her mid to lower back. Fall paperwork filled out...12:18 PM..."

Review of the facility's Interdisciplinary Team Occurrence Investigation revealed no report for the fall on 1/112023.

7. Medical record review revealed that Patient #7 was admitted on 9/13/2022 with an admitting diagnosis of Unspecified Dementia with Behavioral Disturbance.

Review of the Morse Scale (to identify risk factors for falls in hospitalized patients) assessment date 9/30/2022 with a total score of 55 (46 and higher=High Risk), 10/3/2022 total score 70, 10/6/2022 total score 70, 10/13/2022 total score 65.

Review of the nursing progress notes on 10/3/2022 at 1:15 PM revealed, "...This RN is notified of a fall where patient stood from chair and stumbled to the ground...the fall was witnessed and the patient did not hit his head...The exit alarm did activate but staff unable to respond in time; nonslip footwear applied at the time of the fall..."

Review of the Interdisciplinary Team Occurrence Investigation Worksheet on 10/3/2022 at 1:15 PM revealed an incomplete report with a comment and community action plan that stated, "...patient tripped over our feet..." This statement is not what the nursing progress note on 10/3/2022 at 1:15 PM stated. The reason in the nursing progress notes stated, "...stood up from chair ad stumbled to the ground.

Review of the nursing progress notes on 10/8/2022 revealed, "...Patient seen walking in the halls, he tries to sit down in a wheel chair and fall on the ground..."

Review of the Interdisciplinary Team Occurrence Investigation Worksheet on 10/8/2022 at 7:22 PM revealed an incomplete report with an intervention of anti rollbacks place on wheel chair.

In an interview in the group therapy room on 2/15/2023 beginning at 1:39 PM with the Administrator and the Director of Nursing (DON) stated, "...We had discovered that we had a problem with falls and we have already began to work on a action plan starting in December 2022. The DON stated, "...We discussed in the last staff meeting (January 31st) about toileting was out #1 problem with falls so the staff is focusing on taking the patients to the bathroom after meal. We are working on a Fall Focus Team which is not altogether yet...We are working on making sure the occurrence worksheet is completed in it entirety and in servicing the techs and nurses..."

In an interview in the group therapy room on 3/1/2023 at 11:19 AM with Mental Health Tech (MHT) the MHT was asked have you received a new inservice lately related to falls. The MHT stated, "...Yes..." The MHT was asked can you tell me some highlights for the inservice on falls. The MHT stated, "...We when over unwitnessed falls, completing the neuro checks form, taking vitals and filling out a witnessed form on each fall to tell what you know or saw about the patient's fall. The Nurses tell us in the debrief what has been put in place..."

In an interview in the group therapy room on 3/1/2023 at 11:30 AM with the Licensed Practical Nurse (LPN) the LPN #3 was asked have you received a new inservice lately related to falls. The LPN #3 stated, "...Yes..." LPN #3 was asked can you tell me some highlights for the inservice on falls. LPN #3 stated, "...I note if it was a witnessed or unwitnessed fall go and get the RN [Registered Nurse] I check to make sure the legs are even get the vital signs do neuro checks, complete a fall occurrence report, call the doctor and the family member and fill out the witness form..."

In an interview in the group therapy room on 3/1/2023 at 12:25 PM with the Registered Nurse (RN) #2 was asked have you received a new inservice lately related to falls. The RN #2 stated, "...Yes..." RN #2 was asked can you tell me some highlights for the inservice on falls. The RN #2 stated, "...May sure we fill out the Morse Fall Scale on admission and after each fall and weekly...After the fall we assess the patient for any injury that might have received, keep them in line of sight, document a event report, and any staff that is working on your shift even housekeeping if they witnessed the fall will fill out a report on what they witnessed. Look at previous interventions and put a new interventions in place, do a check off sheet and put all your information that you have gathered in a falls binder.

In an interview in the group therapy room on 3/13/2023 at 12:34 PM with the Licensed Practical Nurse [LPN] #4 was asked have you received a new inservice lately related to falls. LPN #4 stated, "...Documentation for falls, interventions, and filling out witness statements also I know there was this table and chairs that all the Tech's sit at and they moved the table and chairs so they would not be sitting at it all the time and would be up and around the patients more..."


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Based on facility document review, policy review and medical record review the facility failed to promote safety by not following facility's policy and procedures, placed all patients at risk for IMMEDIATE JEOPARDY for their safety and well being.

The findings include:

1. Review of the December (reporting for the month of November) QA [Quality Assurance]/PI [Performance Improvement] Meeting Minutes revealed no trends were identified for falls, incidents and critical incidents.

Review of the fall report for October, November, December 2022 and January showed a total of 56 falls with and without injury.

Review of the Team Interdisciplinary Team Occurrence Reports for these falls revealed reports that were incomplete or the reports were never filled out.

2. Review of the December, January and February revealed no data analysis for pain.

Based on facility document review, policy review, medical record review and interview the facility failed to measure, analyze and track quality indicators to ensure an effective QAPI [Quality Assurance]/[Performance Improvement] program.

The finding include:

Review of the December 28, 2022 (reporting for the month of November) QAPI Meeting Minutes revealed, "...Quality Measures...Falls...Were any trends identified...No trends identified...Incidents...Were any trends identified...No trends identified..,Critical Incidents...Were any trends identified...No trends identified..."

Review of the facility fall report from October 2022 to January 2023 revealed the following:
(a) October 2022 - 12 falls
(b) November 2022 - 10 falls
(c) December 2022 - 26 falls
(d) January 2023 - 7 fall

Patient #2 fell into the wall on 12/15/2022 with skin tears to the left elbow and the left knee. The patient was placed on neuro checks after the fall, but was found with no heartbeat that night of the fall at 10:50 PM.

Patient #2 had no Interdisciplinary Team Occurrence Report for his 2 falls.

2. A physician's order documented Patient #3 was taking Eliqus 5 milligram 1 tablet twice a day.

(a) 1/16/23 at 12:15 AM - Laceration head, abrasion right shoulder, skin tear right hand with injury.
(b) 1/17/23 at 6:45 AM - Laceration back of head - fall with injury
(c) 1/21/23 at 2:29 PM fall with no injury
(d) 1/22/23 at 5:45 AM - Laceration back of head - fall with injury
(e) 1/24/23 at 3:00 PM - Bleeding from head/previous suture site - with injury
(f) 1/28/2023 fell out of wheelchair while being transported by staff - without injury
(g) 2/5/23 at 8:55 AM - Hematoma/sm [small] laceration right eye brow.

Patient #3 had no Interdisciplinary Team Occurrence Report for all 8 falls.

3. Patient #4 had the following falls with injury
(a) 11/22/2022 - Hematoma to the forehead
(b) 12/3/2022 - Laceration to Left eyebrow, skin tear to 1st/2nd knuckle area, and skin tear to lateral side of hand below pinky

Patient #4 had no Interdisciplinary Team Occurrence Report for all 3 falls.


4. Patient #5 had the following falls with injury
(a) 1/22/23 at 10:00 PM -Bruising back of head
(b) 1/26/23 at 7:05 AM - Hematoma back of head
(c) 1/26/23 at 3:30 PM - Fracture left hip

Patient #5 had no Interdisciplinary Team Occurrence Report for all 3 falls.


5. Patient #7 had a fall without injury on 10/3/2022.

In review of the Interdisciplinary Team Occurrence Report on 10/3/2022 at 1:15 PM revealed an incomplete report.

In review of the Interdisciplinary Team Occurrence Report on 10/8/2022 at 7:22 PM revealed an incomplete report.

Review of the December 28,2022, January 24, 2023 and February 16, 2023 QA [Quality Assurance]/PI [Performance Improvement] Meeting Minutes revealed no documentation for problems with pain medication.

Refer to A 385

Based on policy review, medical record review, and interview the hospital failed to provide nursing services which provided oversight and supervision to ensure care was provided to meet patient's needs by providing accurate assessments for pain, and the administration of pain medication for 8 of 8 (Patient #1, #2, #3, #4, #5, #6, #7, and #9) sampled patients; failed to ensure nursing services notified physician's of lab results in a timely manner for 2 of 2 (Patient #1 and #6) sampled patients reviewed for lab results; failed to follow the facility policy and providers orders on vital signs for 3 of 3 (Patients #1, #3, and #5) sampled patients, and admission assessment for 1 or 8 (Patient #1) sampled and suicide precautions for 1 of 1 (Patient #1) sampled patients; nursing services failed to ensure physicians orders were obtained for IV [Intravenous] access for 1 or 2 (Physician #1) sampled patients, the administration of oxygen for 1 of 1 (Patient #6) and Physical Therapy service for 1 of 1 (Patient #3) sampled patients; nursing services failed to ensure the complete documentation for neuro checks on 1 of 4 (Patient #4) patients; nursing services failed to follow policy related to the administration of medications.

The finding include:

1. Medical record review for Patient #1 revealed Patient #1, "does not verbalize" at the time of pain assessments. The facility did not provide a non-verbal pain scale to be used to determine the patient's pain level when the pain assessments were done.
The nurses notes documented the patient was given Hydrocodone for pain; however, there was no documentation in the Medication Administration Record (MAR) the patient was given Hydrocodone.
There was no documentation Patient #1 had an accurate reassessment of pain medication.
Patient #1 had a urinalysis in which the results were abnormal revealing a Urinary Tract infection (UTI). The abnormal urinalysis results were not called to the physician/provider and the UTI went untreated for 8 days.
The physician's orders revealed vital signs were ordered 3 times a day. The care plan documented specific parameters for each patients blood pressures, both the systolic and diastolic blood pressures. Patient #1 vital signs did not get taken 3 times a day ever day and the diastolic blood pressure that were outside the parameter were not documented as reported to the physician/provider.
A physician order documented to administer intravenous fluids but there was no documentation of a physician's order to obtain Intravenous access. The MAR documented the fluids were not administered as ordered by the physician.
Review of the nursing notes documented Patient #1 refused all medication on 1/21/2023; however, the MAR documented the patient's medications were administered.
Review of the MAR revealed the patient did not take medications on specific dates or missed the dose; however, there was no documentatation of an explanation why the patients did not receive the medications.
Review of admission physician's orders dated 1/12/2023 revealed a physician's order's for Suicide Precautions; however, review of the psychiatric notes revealed there was not reason for the patient to be on suicide precautions.

2. Medical record review for Patient #2 revealed there was no pain assessment upon admission although the patient was care planned for chronic pain.

3. Medical record review for Patient #3 revealed the patient was "unable to Rate [pain] due to cognition" at the time the pain assessments were documented as completed. The facility had no documentation of a non-verbal pain scale to be used to determine a patient's pain. Pain assessments were not documented as done every shift. The facility may have no pain assessments documented. When a pain assessment was documented, there was no documentation of interventions noted for pain. There was no documentation vital signs were obtained three times per day as ordered. There was specific parameters documented for the dialstolic blood pressures and if blood pressure was outside the ordered parameters there was no documentation they were reported to the physician/provider.
Review of the provider orders and the physical therapy notes revealed no provider orders for the physical therapy provided to Patient #3 on 1/19/2023, 1/30/2023, 1/31/2023, 2/3/23, 2/6/23, 2/7/23, 2/9/2023 and 2/13/2023.

4. Medical record review revealed Patient #4 had no documentation a pain assessment was completed from admission on 11/18/22 until discharge on 12/10/2022. There was no documentation Patient #4 had neuro check completed.

5. Medical record review revealed Patient #5 had no documentation pain assessments were complete. When documentation of a pain assessment was available, there were no interventions and no reassessment of the pain after medication administration. There was no documentation Patient #5 had vital signs obtained 3 times a day ever day. If the diastolic blood pressure for the patient was not within specific acceptable parameters, there was no documentation the physician/provider was notified.

6. Medical record review for Patient #6 revealed an abnormal urinalysis indicatitive of Urinary Tract infection. There was no documentation the abnormal lab results were called to the physician/provider for 7 days. Patient #6 had pain assessments but there was no documentations of interventions. There was no documentation Patient #6 received a pain assessment and there was no documentation of interventions for pain assessments. There was no documentation of reassessments of pain done in a timely manner. There was no documentation of a physician's order for oxygen administered to the patient.

7. Medical record review revealed there was no documentation of a pain assessment for Patient #7 on 9/30/2022 or 10/1/2022.

8. Medical record review for Patient #9 revealed there was no pain assessment documented on some days. There was no documentation of pain assessments every day, no documentation of reassessment of pain after pain medications were administered and no documentation of timely reassessments of pain. The nurses notes documentated the patient was given ativan but received no pain assessments on some days, no reassessments of pain medication, not timely reassessments of pain medication. There was documentation in the nurses notes Ativan was given but no documentation the medication had been given in the MAR.

Refer to A 395

Based on review of policy review, medical record review, document review and interviews, the hospital failed to ensure nursing services provided an effective pain scale to assess patient's pain correctly, ensure interventions were followed for the administration of pain medication and pain reassessments were completed for the effectiveness of pain medication for 8 of 8 (Patient #1, #2, #3, #4, #5, #6, #7 and #9) sampled patients; the facility failed to ensure an organized nursing service notified the physician of lab results in a timely manner for 2 of 2 (Patient #1 and #6) sampled patients; nursing services failed to ensure staff followed the physician orders and facility's policy for vital signs, for 3 of 3 (Patient #1, #3 and #5) sampled patients and suicide precautions for 1 of 1 (Patient #1) sampled patients; the facility failed to ensure physician orders were obtained for the administration of Intravenous access for 1 of 2 (Patient #1) sampled patients, for the administration of oxygen for 1 of 1 (Patient #6) patient's review for oxygen and for Physical Therapy services for 1 of 1 (Patient #3) sampled patients reviewed; nursing services failed to ensure physician orders were discontinued, new orders were obtained and written for 1 of 2 (Patient #1) sampled patients; nursing services failed to follow the facility policy for new admissions for 1 of 7 (Patient #1) patients; nursing services failed to provide documentation for the administration of medication for 2 of 7 (Patient #1 and #7) sampled patients; nursing serviced failed to ensure complete documentation for neuro check on 1 of 4 (Patient #4) patients reviewed for neuro checks; and nursing services failed to administer medications correctly for 2 of 8 (Patient #1 and #9) reviewed for the administration of medications.

The finding include:

1. Review of the facility's "Laboratory Service" policy with a revised date of "10/2020" revealed, "...A physician may request laboratory test on patients, a physician order is written for the specified requested laboratory procedure...The charge nurse will check off the physician's orders. The lab will be obtained as soon as possible...If the physician orders a stat lab, the contracted lab will be notified of the need for stat services. Lab will notify [Named Facility] #1 of results by phone and fax. The physician will be notified of results when received by charge nurse. The date and time the physician was notified will be recorded in progress notes...The Charge nurse will follow-up on all orders to ensure the timely obtaining of the results. The physician will not be notified of normal lab unless requested..."

Review of the facility's "Pain Assessment" policy with a revised date of "12/2020" revealed, "A pain assessment will be completed by a nurse during the initial assessment. The assessor should include the following: Where the pain is located, the quality of pain, the intensity level of pain, the patient's goal for pain controls, what relieves the pain, what increases pain and what medications relieves pain from cognitive patient..."

Review of the facility's "Vital Signs, Weight, and Intake"policy with a revised date of "5/2021" revealed, "...It is the policy...to routinely monitor vital signs three times daily unless otherwise indicated by physician's order..Vital Signs...are monitored by the nurse, recorded in the electronic health record, and reported to the physician as appropriate..."

Review of the facility's "Medication Administration" policy with a revised date of "8/2021" revealed, "...All orders medication shall include the date and time of the order, the name of the drug, the dosage, the route, the frequency of the administration...the reason the medication is ordered for the patient...Timing of medication administration...Non-time scheduled medications are those for which a longer or shorter interval of time since the prior dose not significantly change the medication therapeutic effect...Medications prescribed for daily, weekly, or monthly administration may be within two (2) hours before or after the scheduled dosing time, for a total window that does not exceed (4) hours...Medications prescribed more frequently than daily but no more frequently that every four (4) hours may be administered within one (1) hour before or after the scheduled dosing time, for a total window that does not exceed two (2) hours...Physician's orders shall be sent to the Pharmacy as soon as possible after a medication or discharge order is written...Each dose of medication administered shall be properly recorded in the patient's medical record..."

Review of the facility's "Nursing Assessment" policy with a revised date of "11/2022" revealed, "..Nursing Assessment (initial assessment) on all newly admitted patients within 24 hours of admission...The RN [Registered Nurse] will electronically sign when completed which will additionally capture the completion date and time..."

Review of the facility's "Medical Records Standard" policy with a revised date of "08/2021" revealed, "...Entries will be complete when it contains the sufficient information to identify the patient, support the diagnosis/condition, justify the care, treatment, and services' document the course and results of care, treatment, services and promote the continuity of care...Late entries and addendums must reflect the date, time, and signature of the author. Entries must not give the appearance that the entry was made on a previous date or an earlier time. Late entries and addendums must refer to the circumstances for which it was written or added. Late entries and addendums must be completed as soon as possible. The longer the time lapse the less reliable the entry becomes..."

2. Medical record review revealed that Patient #1 was admitted with on 1/12/2023 with an admitting diagnosis of Alzheimer's Disease with late onset.

(a) labs
Review of the Client Doctor Orders on 1/12/2023 at 11:36 PM revealed an order for a urinalysis complete with culture.

Review of the plan of care for Patient #1 on 1/13/2023 revealed, "...Problem: Urinary Tract Infection...Goal: Patient #1 will have negative urine culture results by end of hospital stay...Objective: Patient #1 will be without elevated temperature or symptoms of dysuria over the next 10 days...Interventions...Nursing to administer all medications as ordered...Staff to encourage Patient #1 to empty her bladder completely when voiding..."

Review of the lab results revealed the date and time the specimen was collected was 1/14/2023 at 6:00 AM and it was received at the lab on 1/15/2023 at 3:01 AM. The results were reported on 1/17/2023 at 9:18 PM.

Review of the Inpatient progress note created on 1/15/2023 with a date of service on 1/13/2023 at 10:17 AM revealed, "...Active Problems: UTI [Urinary Tract Infection]...Pain, Age of Onset 73..."

Review of the Inpatient progress notes on 1/19/2023 revealed, "...The following orders were placed in the last 24 hours: Med: Bactrim DS [Double Strength] oral tablet, 1 tablet twice a day oral..."

Review of the Client Doctors Orders on 1/20/2023 at 5:50 AM revealed Bactrim DS [Double Strength] 800 MG [milligram]-160 MG was ordered 1 tablet twice a day for Urinary Tract Infection.

Review of the Medication Administration Orders [MAR] revealed Bactrim DS [Double Strength] was first administered on 1/20/2023 at 8:15 AM (8 days after the Urinalysis lab test was ordered).

Review of the Inpatient progress notes on 1/20/2023 revealed, "...Lab results Urinalysis W [with]/Micro [microscopis]..."

Review of the Inpatient progress notes on 1/21/2023 revealed, "...She has recent dx [diagnosis] of UTI [Urinary Tract Infection], antibiotics ordered by medical..."

Review of the nursing flowsheet on 1/21/2023 at 8:00 AM revealed, "...Continent Bowel and Bladder...Bactrim DS [Double Strength] oral 1 tablet twice a day, Start Date: 1/20/2023...Summary 8:45 PM...Patient #1 declined all medications this shift 1/21/2023..."

Review of the MAR on 1/21/2023 revealed that a Bactrim DS, was administered at 8:46 AM.

Review of the individual nursing progress notes on 1/23/2023 at 8:00 AM revealed, "...4:30 PM...Patient #1 voided moderate amount of cloudy yellow urine into toilet..."

Review of the documents on 1/24/2023 at 11:21 PM from Named Hospital #1 revealed that Patient #1 was admitted with diagnoses of Decreased Oral Intake, Dehydration and Acute Kidney Injury.

In an interview on 3/1/2023 at 12:25 PM in the group therapy room RN #2 was asked the process for reporting a lab result to the physician or provider. RN #2 stated, "...We have a board that listed all the labs that are pending at the lab and we check them on our shift to see if there are results; if they have resulted we print them off and put them in the doctors binder for them to check when they come in to make their rounds. RN #2 was asked do you not call the physician and let him know you have abnormal labs. RN #2 stated, "...No, I do not he has a computer to look them up just like I can or he can see it when he comes in to make rounds they are in his binder or basket..."

In an interview in the group therapy room on 3/1/2023 at 3:18 PM with the Regional Nurse Manager (RNM) stated, "...I have been researching Patient #3's chart and I have been unable to find the documentation to give you any answers (why did it take so long to collect the specimen for the urinalysis and why did it take so long to start the antibiotic after the results came back); what I have been able to find out is the same information that you have found in the chart. The Regional Nurse Manager [RNM] was asked do you think the time frame (9 days after the order and 3 days later after the results came back) was acceptable to start the antibiotic for this Urinary Tract Infection on 1/20/2023. The RNM stated. "...No..."

(b) pain
Review of the Client Doctor Orders on 1/12/2023 revealed an order for Acetaminophen 325 mg [milligram] tablet 2 tablets every 4 hours for pain.

Review of the Client Doctor Orders on 1/12/2023 revealed an order for Hydrocodone 325 milligram 5 milligram oral tablet 1 tablet every 4 hours for pain.

Review of the nursing assessment for admission on 1/12/2023 did not reveal a documented pain assessment.

Review of the nursing flowsheet on 1/14/2023 at 9:00 AM revealed, "...Pain Assessment: Not Present...Nonverbal Expression: Grimacing..."

Review of the individual nursing progress notes on 1/14/2023 at 1:20 PM revealed, "...Patient verbalizes that her legs hurt. Facial grimacing noted. Will administer hydrocodone per PRN order for pain (med [Medication] nurse retrieving from narc [narcotic] box per protocol)..."

Review of the Medication Administration Record (MAR) on 1/14/2023 revealed no documentation Hydrocodone was administered for pain.

Review of the Inpatient progress note created on 1/15/2023 with an date of service on 1/13/2023 at 10:17 AM revealed, "...Active Problems...Pain, Age of Onset 73...Psychiatric History: Unable to meaningfully obtain from the patient due to her dementia and current mental status..."

Review of the nursing flowsheet on 1/16/2023 at 8:00 AM revealed no documented pain assessment.

Review of the Inpatient progress note on 1/16/2023 revealed, "...She exhibits labile mood with crying and then irritability during this visit...pt [patient] seen in dining room; easily tearful and cries during this entire interaction. she does not verbalize reason for this. no aggression at this time..."

Review of the nursing flowsheet on 1/17/2023 at 8:00 AM revealed no documented pain assessment.

Review of Inpatient progress note on 1/17/2023 revealed, "...Chief Complaint: does not verbally engage: tearful during interaction..."

Review of the nursing flowsheet on 1/19/2023 at 8:00 AM revealed, "...Nonverbal Expression: Grimacing..."

Review of the nursing flowsheet on 1/20/2023 at 8:00 AM revealed, "...Pain Assessment: Not Present...Nonverbal Expression: crying/Moaning..."

Review of the nursing flowsheet on 1/20/2023 at 8:45 PM revealed, "...Pain Assessment: Present...Pain Scale 1-2 Mild Pain...Nonverbal Expression: Crying/Moaning...Quality of Pain: Tender/Sensitive, Throbbing...Pain Interferes with: Eating, sleeping, Personal Activity...Pain Comments and Additional Information: complained of right hip pain. X-ray'ed this date - unremarkable and has intact right arthroplasty..."

Review of the nursing flowsheet on 1/22/2023 at 10:30 AM revealed no documented pain assessment.

Review of the nursing flowsheet on 1/23/2023 at 8:00 AM revealed, "...Nonverbal Expression: Crying/Moaning..."

Review of the individual nursing progress notes on 1/23/2023 at 8:00 AM revealed, "...When asked if she is hurting anywhere, patient states "my legs"..."

Review of the Individual progress notes on 1/23/2022 revealed, "...does appear frail and week [weak]. She is crying and will barely speak...Looking off to side and down at her knees and she cries and wails loudly..."

Review of the individual progress note on 1/24/2023 at 9:35 PM revealed, "...No aggression and combativeness noted...Responds to questions with confused speech...When asked if she is hurting anywhere, patient states "my legs".

In an interview in the group therapy room on 3/1/2023 at 12:25 PM with the Registered Nurse [RN] #2 was asked does this facility provide you with a non-verbal scale to assess your patient's pain. RN #2 stated, "No". RN #2 was asked how do you assess your patient's pain level to decide whether it is mild, moderate or severe. RN #2 stated, "...I use my years of nursing experience..." RN #2 was asked how often do you assess pain on your patients. RN #2 stated. "...At the beginning of each shift..."

In an interview in the group therapy room on 3/2/2023 at 9:34 AM with the Director of Nursing (DON) was asked to what type of pain scales do you use at this facility. The DON stated, "We use the 1-10 pain scale. The DON was asked what type of of pain scale do you use for your non-verbal and cognitive impaired patients. The DON stated, "...I just use my years of nursing experience..." The DON was asked how do you know if the patient's pain is mild, moderate or severe. The DON stated, "...Well if the patient has a frown on their face it is probably mild...if the patient is crying it is probably severe..." The DON was asked if the patient is not verbal or cognitive impaired should anything on the pain scale be filled out other that the nonverbal expression. The DON stated, "No".

In an interview in the group therapy room on 3/2/2023 at 11:15 AM with the RNM the RNM stated, "...On the 14th was the first charted pain was at 1:20 PM and I noticed that Patient #1 was given Ativan PRN [as needed] the nurse could have given the patient that instead of the pain medication. The RNM was asked if the Ativan was order for pain. The RNM stated it was order for agitation. She also gets Ativan PO [by mouth] three times a day....On the 20th I could find nothing given for pain. On the 23th the patient refused everything she was offered..."

In an interview in the group therapy room on 3/13/2023 at 12:34 PM with RN #4 was asked tell me about your recent inservice on pain. RN #4 stated, "...We have a nonverbal scale to use which is the Flacc Scale to use now, the inservice talked about documentation of pain and reassessment and the documentation of the reassessment and the timing of giving our pain medication..."

(c) vital signs
Review of the Client Doctor Orders on 1/12/2023 revealed an order for vital signs three times a day.

Review of the plan of care for Patient #1 on 1/13/2023 revealed, "...Problem: Potential for Blood Pressure Dysregulation...Goal: Patient's #1 blood pressure will be within range of systolic: 90-160 and diastolic: 60-70 for 7 consecutive days and by end of hospital stay...Objective...Patient #1 will be without dizziness or weakness related to blood pressure changes over the next 5 days...Interventions...Obtain Patient #1's blood pressure 3x [3 times] daily...Nursing to review signs and symptoms of hyper/hypo-tension and importance of reporting them...Staff to monitor Patient #1 for complaints of sudden weakness of dizziness and nursing to notify MD if present..."

Review of the Vital Sign Report revealed the following:

1/14/2023-Only one set of vital sign was taken at 10:05 PM instead of the three as was ordered by the physician.

1/15/2023 at 3:18 PM- Blood Pressure-138/84. There was no documentation the diastolic BP was reported to provider as not being within the ordered parameters. There were two sets of vital signs taken one at 8:02 AM and 3:18 PM instead of the three as order by the provider.

1/16/2023 at 1:48 AM Blood Pressure-132/87. There was no documentation the diastolic BP was reported to provider as not being within the ordered parameters. Blood Pressure at 11:25 PM -Blood Pressure 136/31. There was no documentation the diastolic BP was reported to provider.

1/17/2023 Blood Pressure at 9:54 PM-129/55. There was no documenation the diastolic BP was reported to provider as not being within the ordered parameters. There were only two sets of vital signs taken at 7:31 AM and 9:54 PM instead of the three as was ordered by the physician.

1/18/2023 at 8:45 AM Blood Pressure 121/99. There was no documentation the diastolic BP was reported to the provider as not being within the ordered parameters. The patient's Blood Pressure at 11:00 PM was 131/44. There was no documentation the diastolic BP was reported to the provider as not being within the ordered parameters. There are two sets of vital signs taken at 8:45 AM and 11:00 PM instead of three as ordered by the physician.

1/19/2023 at 10:13 PM-Blood Pressure 125/51. There was no documentation the diastolic BP was reported to provider as not being within the ordered parameters.

1/20/2023-Only one set of vital signs taken at 7:02 AM instead of three as ordered by the physician.

1/21/2023 at 10:44 PM-Blood Pressure 124/93. There was no documentation the diastolic BP was reported to provider as not being within the ordered parameters. There are two sets of vital signs taken at 10:44 PM and 12:18 AM instead of three as ordered by the physician.

1/22/2023 at 7:28 AM-Blood Pressure 163/88. There was no documentation the diastolic BP was reported to provider as not being within the ordered parameters. There are one set of vital signs taken at 7:28 AM instead of three as ordered by the physician.

In an interview in the group therapy room on 3/1/2023 at 11:19 AM with Mental Health Tech (MHT) the MHT was asked who takes the vital signs. The MHT stated, "...MHT's." The MHT was asked how many times a day are vital signs taken and at what times. The MHT stated, "...We take the vital signs 3 times a day the day shift vitals are taken between 12:30 PM - 1:00 PM. The night shift takes them around shift change at 7:00 PM and at 6:00 AM in the morning.

(d) IV
Review of the Client Doctor Orders dated 1/12/2023 through 1/25/2023 revealed there was no documentation for an order to start an IV [Intravenous] line to administer IV [Intravenous] fluids.

Review of the MAR on 1/23/2023 at 3:30 PM revealed an order for "...0.45% [percent] Sodium Chloride 1000 Milliliter Stat - Give 1000mL [milliliter] 1/2 NS [Normal Saline] was administer by Nurse #2 at 100mL [milliliter]/hr [hour]..." Nurse #2 did not administer the medication as ordered by the physician.

Review of the individual nursing progress notes on 1/23/2023 at 3:30 PM revealed, "...IV inserted to left AC [antecubital] (attempted x [times] 2 by...student RN [Registered Nurse], and inserted X 1 attempt by me). 1/2 NS @ [at] 100ml /hr initiated. Patient tolerated fairly well...Patient being monitored 1:1 during IV fluid infusion...4:30 PM...22 G [gauge] left AC infiltrated; small amount of edema & coolness at site. IV removed (cath tip intact); pressure applied...4:30 PM 22G [needle] left AC infiltrated..." There was no physician order to start an IV line.

Review of the Client Doctor Orders on 1/23/2023 at 4:03 PM revealed an order for Sodium Chloride (1/2) Normal Saline) 1000 milliliter Stat...Give 1000 mL 1/2 NS [Normal Saline] fluid bolus.

Review of the individual progress note on 1/24/2023 revealed, "...Plan of Care 1/23/2023...1/2 Normal Saline 1 liter for dehydration...Patient continues to have poor PO [by mouth] intake despite encouragement IV attempted..." There was no documentation the physician ordered placement of an IV line.

Review of the individual nursing progress notes on 1/24/2023 at 5:00 PM revealed, "...RN #1 tried to start a IV on her foot and breast, unsuccessful..."

Review of independent note on 1/24/2023 at 6:47 PM revealed, "...Patient was handed to ems [Emergency Medical Service] in order to be transferred to [Named Hospital] #1 in order to receive hydration..."

In an interview in the group therapy room on 3/1/2023 at 2:33 PM with the Director of Nursing [DON] stated, "...She was not the nurse that tried to start the IV in the breast but she did try to start it in the foot. The DON was asked why she tried to start the IV line in the foot since the patient was noted to be a wanderer and was a diabetic. The DON stated, "...Patient #1 had declined and was not up walking but was in a wheelchair and it was a doctors order. The DON was asked who tried to start the IV in the breast. The DON stated it was Nurse #2. It really wasn't in the breast it was a vein that went down beside the breast.

In an interview in the group therapy room on 3/1/2023 at 2:50 PM the Regional Nurse Manager [RNM] stated, "...On the order for Patient #1 to received 1000 milliliter bolus...the nurse called the Nurse Practitioner and stated that the patient was so little she could not tolerate that bolus so the Nurse Practitioner changed the order. The RNM was asked if the previous order for the 1/2 Normal Saline had been discontinued and a new order written for the 1/2 Normal Saline at 100 milliliter a hour...The RNM...It states on the MAR that the Nurse gave the 1/2 Normal saline at 100mL/hr. The RNM was asked again it the was the previous order discontinued and a new order written. The RNM stated, "...No..."

(e) Nursing Assessments
Review of the initial nursing assessment had a created date of 1/16/2023 and a assessment date of 1/12/2023. The initial nursing assessment was not completed within 24 hours of hospital admission.

Review of the Braden Scale created on 1/15/2023 with an assessment date of 1/12/2023. The Braden scale assessment was not completed within 24 hours of hospital admission.

Review of the wandering assessment created on 1/16/2023. The wandering assessment was not completed within the 24 hours of hospital admission.

Review of the COWS [Clinical Opiate Withdrawal Scale] with a created date of 1/15/2023 with the assessment date of 1/13/2023. The assessment was not completed within 24 hours of hospital admission.

Review of the Abnormal Involuntary Movement Scale [AIMS] with the dated created as 1/15/2023 and an assessment date of 1/12/2023. The AIMS assessment should have been completed within 24 hours of hospital admission.

Review of the Clinical Institute Withdrawal Assessment for Alcohol [CIWA] with a created date of 1/15/2023 and an assessment date of 1/13/2023. The CIWA should have been completed within 24 hours of hospital admission.

Review of the Skin Assessment with a created date of 1/15/2023 and an assessment date of 1/12/2023. The skin assessment should have been completed within 24 hours of hospital admission.

In an interview in the group therapy room on 3/1/2023 beginning at 1:20 PM with RNM stated, "...The administration paperwork should have been completed within 24 hours of admission. Admission nursing assessment, the Braden Scale, the wandering assessment, Clinical Opiate Withdrawal Scale, Abnormal Involuntary Movement Scale, Clinical Institute Withdrawal Assessment for Alcohol and the skin assessment..."

(f) Medication Administration

Review of the Client Doctor Orders on 1/12/2023 revealed an medication order for Ativan 0.5 mg [milligram] 1 tablet every 8 hours.

Review of the Client Doctor Orders dated 1/12/2023 revealed an medication order for Depakote 250 mg [milligram] 1 tablet twice a day.

Review of the MAR dated 1/13/2023 at 5:01 AM, 2:15 PM and 7:48 AM revealed missed dose of Patient #1's Ativan 0.5 mg 1 tablet every 8 hours. There was no documentation why Patient #1 missed the ordered medication. This medication was order at 6:00 AM, 2:00 PM and 10:00 PM.

Review of the MAR dated 1/13/2023 at 7:03 AM revealed a missed dose of Depakote 250 mg. There was no documentation why this medication not administered.

Review of the Client Doctor Orders dated 1/17/2023 at 8:00 PM revealed a medication order for Ativan 0.5 mg 1 tablet as needed PO or IM for anxiety, agitation or aggression.

Review of the MAR dated 1/17/2023 at 10:40 PM revealed Ativan 0.5 mg 1 tablet was administered. Further review of MAR documentation revealed the medication was effective 1/20/2023 at 4:15 AM (2 days later).

Review of the nursing flowsheet dated 1/21/2023 at 8:00 AM revealed, "...Continent Bowel and Bladder...Bactrim DS oral 1 tablet twice a day, Start Date: 1/20/2023...Summary 8:45 PM...Patient #1 declined all medications this shift 1/21/2023.

Review of the daily nursing shift assessment on 1/21/2023 at 8:45 PM revealed, "...She declined all medications this shift.

Review of the MAR dated 1/24/2023 at 7:00 PM revealed Ativan 0.5 mg tablet was administered three hours early. There was no documentation why the medication was administered early and no documentation the physician had been notified.

(g) Suicide Precaution
Review of the Client Doctor Orders on 1/12/23 11:36 PM revealed an order for suicide precautions with a start date and time of 1/12/2023 at 11:32 PM and a discontinued date of 1/25/2023 at 1/25/2023 at 12:14 PM.

Review of the Psychiatric Inpatient progress note dated 1/15/2023 through 1/20/2023 revealed no documentation related to suicide precautions.

In an interview in the group therapy room on 3/2/2023 at 1:45 PM with the RNM was asked if there was a plan of care completed for Patient #1's suicide. RNM stated, I have looked at the patient's record and there was not a care plan documented for suicide precautions; but there was a suicide assessment done. This surveyor requested a copy of the suicide assessment several times but it was not provided; instead the RNM provided the surveyor the Inpatient progress notes from the psychiatric providers and stated, "...This documentation would show she was not identified suicide precautions..."

3. Medical Record Review revealed that Patient #2 was admitted on 12/13/2022 with a diagnosis of Alzheimer's Disease with late onset.

Review of the nursing flowsheet dated 12/13/2023 at 8:00 PM revealed, there was no pain assessment documentated for the 7:00 PM - 7:00 AM shift

Review of the plan of care dated 12/14/2022 revealed, "...Problem Code: Pain, chronic...Goal: Pain will be controlled daily at level acceptable to Patient #2 for seven consecutive days by end of hospital stay...Objectives...Patient #2 will verbalize acceptable pain level to nurse daily over next 5 days...Interventions...Nursing will monitor effectiveness of medications to control pain, if needed and notify MD [Medical Doctor] if non-effective...Nursing will observe Patient #2 for nonverbal and behavioral signs of pain...Staff will promote comfort and assist Patient #2 with proper body alignment and positioning when needed..."

4. Medical record review dated 1/14/2023 revealed Patient #3 was admitted with a diagnosis of Dementia Psychotic Disturbance.

(a) pain
Review of the Client Doctor Orders dated 1/14/2023 revealed a medication order for Acetaminophen 325 mg [milligram] 2 tablets every 4 hours as needed for pain.

Review of the nursing flowsheet dated 1/16/2023 at 7:30 AM revealed there was no documentation a pain assessment was completed.

Review of the nursing flowsheet dated 1/17/2023 at 11:30 AM revealed there was no documentation a pain assessment was completed.

Review of the nursing flowsheet dated 1/20/2023 at 8:00 AM revealed, "...Pain Assessment: Present...Pain Scale: 1-2 Mild Pain...Patient reports mild headache, unable to rate due to cognition..."

Review of the nursing flowsheet dated 1/20/2023 at 8:55 PM revealed, "...Pain Assessment: Present...Pain Scale: 1-2 Mild Pain...Nonverbal Expression: Grimacing...Quality of Pain: Tender/Sensitive, Sore...What makes the pain worse?: "just hurts"...What makes the pain better?: no response...Patient Comments and Additional Information: pain to right ear with lacerations from fall...Finger lacerations from fall...Forehead tender from fall...Skin Comments...multi skin tears, scabs, head lacerations with SSS [Stainless Steel Staples], senile bruising...Patient reports mild headache, unable to rate due to cognition...Fall on 1/17 in dining room from wheelchair with head laceration...Fall on 1/18 in dining room from wheelchair with head laceration...Lacerations to his head have SSS [stainless steel staples] and intact scabbing..."

Review of the nursing flowsheet dated 1/25/2023 at 7:40 PM revealed, "...Pain Scale: 1-2 Mild Pain...Nonverbal Expression: Grimacing...Quality of Pain: Tender/Sensitive, Sore...Patient Comments and Additional Information: head is tender with multi scalp lacerations with SSS...Unwitnessed fall on 1/24 with no apparent injuries noted..."

Review of the nursing flowsheet dated 1/27/2023 at 10:17 AM revealed, "...Pain Scale: 1-2 Mild Pain...Quality of Pain: Cramping...Patient Comments and Additional Information: C/O [complained of] abdominal discomfort, he had just finished breakfast at this time..." There was no interventions documented to address Patient #3's pain.

In an interview in the group therapy room on 3/1/2023 at 12:25 PM, Registered Nurse [RN] #2 was asked does this facility provided you with a non-verbal scale to assess your patient's pain. RN #2 stated, "No". RN #2 was asked how do you assess your patient's pain level to decide whether it is mild, moderate or severe. RN #2 stated, "...I use my years of nursing experience..." RN #2 was asked how offer to you assess pain on your patients. RN #2 stated. "...At the beginning of each shift..."

In an interview in the group therapy room on 3/2/2023 at 9:34 AM with the Director of Nursing (DON) was asked to what type of pain scales do you use at this facility. The DON stated, "We use the 1-10 pain scale. The DON was asked what type of of pain scale do you use for your non-verbal and cognitive impaired patients. The DON stated, "...I just use my years of nursing experience..." The DON was asked how do you know if the patient's pain is mild, moderate or severe. The DON stated, "...Well if the patient has a frown on their face it is probably mild...if the patient is crying it is probably severe..." The DON was asked if the patient is not verbal or cognitive impaired should anything on the pain scale be filled out other that the nonverbal expression. The DON stated, "No".

In an interview in the group therapy room on 3/2/2023 at 11:15 AM with the RNM the RNM stated, "...On the 14th was the first charted pain was at 1:20 PM and I noticed that Patient #1 was given Ativan PRN [as needed] the nurse could have given the patient that instead of the pain medication. The RNM was asked if the Ativan was order for pain. The RNM stated it was order for agitation. She also gets Ativan PO three times a day....On the 20th I could find nothing given for pain. On the 23th the patient refused everything she was offered..."

In an interview in the group therapy room on 3/13/2023 at 12:34 PM, RN #4 was asked to tell me about your recent inservice on pain. RN #4 stated, "...We have a nonverbal scale to use which is the Flacc Scale to use now, the inservice talked documentation of pain and reassessment and the documentation of the reassessment and the timing of giving our pain medication..."

(b) Vital Signs
Review of the Client Doctor Orders dated 1/14/2023 revealed an order for vital signs 3 times a day.

Review of the plan of care on 1/14/2023 revealed a problem of Hypertension...Goal...Patient #1's blood pressure will be within range of systolic: 90-160 and diastolic: 60-90 for 7 consecutive days by end of hospital stay...Objective...Patient #2 will be without dizziness or weakness related to blood pressure changes over the next 5 days...Interventions...Nursing will review with Patient #2 signs and symptoms of hyper/hypo-tension and importance of reporting them...Staff will obtain Patient #2's blood pressure 3x [times] daily..."

Review of the Vital Signs Report revealed the

Based on review of the Emergency Medical Services [EMS] Transport Report, medical record review, and document review the facility failed to maintain complete and accurate medical records in regards to patients being transported from Named Hospital #2 to Named Hospital Emergency Room [ER] #1 for 12 of 33 (Patient #3, #4, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) sampled patients reviewed.

The finding include:

1. Review of the EMS transport report dated 10/3/2022 through 1/12/1023 from Named Hospital #2 to Named Hospital #1 revealed 12 patients not listed on Named Hospital #2 transfer long.

2. Patient #3 was transported to ER #1 on 1/19/2023 with a chief complaint of a fall.

3. Patient #4 was transported to ER #1 on 12/10/2022 with a chief complaint of difficulty breathing.

4. Patient #10 was transported to ER #1 on 10/3/2022 with a chief complaint of Shortness of Breath.

5. Patient #11 was transported to ER #1 on 12/3/2022 with a chief complaint of refusing to eat.

6. Patient #12 was transported to ER #1 on 12/3/2022 with a chief complaint the patient was unresponsive.

7. Patient #13 was transported to ER #1 on 12/6/2022 with the chief complaint of being Altered Mental Status.

8. Patient #14 was transported to ER #1 on 12/6/2022 with the chief complaint of difficulty breathing.

9. Patient #15 was transported to ER #1 on 12/12/2022 with the chief complaint of a Stroke.

10. Patient #16 was transported to ER #1 on 12/22/2022 with the chief complaint of a fall and vomiting.

11. Patient #17 was transported to ER #1 on 12/23/2022 with the chief complaint of Syncope.

12. Patient #18 was transported to ER #1 on 1/16/2023 with the chief complaint of a fall.

13. Patient #19 was transported to ER #1 on 1/16/2023 with the chief complaint of abnormal lab results.

Refer to A 467

Based on document review, medical record review, review of the Emergency Medical Services [EMS] Transports Report, and interviews the facility failed to enter all patients on the transfer log for 12 of 33 (Patient #3, #4, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) sampled patients who were transported to the Emergency Department for care.

The finding include:

1. Review of the EMS transport log from 10/3/2022 through 1/12/1023 from [Named Hospital] #2 to [Named Hospital] #1 revealed an incomplete log. A total of 12 patient were not listed on the transfer log that were transferred from [Named Hospital #2 to [Named Hospital] #1.

2. Review of the medical record review revealed Patient #3 was admitted on 12/22/2022 with a diagnosis of Dementia in other diseases classified elsewhere as severe, with Psychotic Disturbance.

Review of the EMS transport log 1/19/2023 revealed that Patient #3 was transferred to Named Hospital #1 for evaluation of a Fall.

3. Review of the medical record review revealed Patient #4 was admitted with a diagnosis of Unspecified Dementia, Unspecified Severity, with Agitation.

Review of the EMS transport log on 12/10/2022 revealed Patient #4 was transferred to the Named Hospital #2 for difficult breathing.

4. Review of the medical record review revealed Patient #10 was admitted on 9/9/2022 with a diagnosis of Alzheimer's Disease.

Review of the EMS transport log on 10/3/2022 revealed Patient #10 was transferred to the Named Hospital #1 for Shortness of Breath.

5. Review of the medical record review revealed Patient #11 was admitted on 11/4/2022 with a diagnosis of Bipolar Disorder.

Review of the EMS transport log on 1/11/2022 revealed Patient #11 was transferred to the Named Hospital #1 for Refusing to Eat.

6. Review of the medical record review revealed Patient #12 was admitted on 11/25/2022 with a diagnosis of Unspecified Dementia .

Review of the EMS transport log on 12/3/2022 revealed Patient #12 was transferred to the Named Hospital #1 for Unresponsiveness.

7. Review of the medical record review revealed Patient #13 was admitted on 12/5/2022 with a diagnosis of Brief Psychotic Disorder .

Review of the EMS transport log on 12/6/2022 revealed Patient #13 was transferred to the Named Hospital #1 for Altered Mental Status.

8. Review of the medical record review revealed Patient #14 was admitted on 12/9/2022 with a diagnosis of Schizoaffective/ Bipolar Type.

Review of the EMS transport log on 12/10/2022 revealed Patient #14 was transferred to the Named Hospital #1 for difficult breathing.

9. Review of the medical record review on revealed Patient #15 was admitted on 12/2/2022 with a diagnosis of Psychotic Disorder with Delusions due to known Physiological Condition.

Review of the EMS transport log 12/12/2022 revealed Patient #15 was transferred to the Named Hospital #1 for Stroke.

10. Review of the medical record review revealed Patient #16 was admitted on 12/19/2022 with a diagnosis of Schizoaffective Disorder/Bipolar Type.

Review of the EMS transport log 12/22/2022 revealed Patient #16 was transferred to the Named Hospital #1 for a fall and vomiting.

11. Review of the medical record review revealed Patient #17 was admitted on 12/22/2022 with a diagnosis of Alzheimer's Disease.

Review of the EMS transport log 12/23/2022 revealed Patient #17 was transferred to the Named Hospital #1 for a Syncope.

12. Review of the medical record review revealed Patient #18 was admitted on 12/22/2022 with a diagnosis of Major Depressive Disorder.

Review of the EMS transport log 1/16/2023 revealed Patient #18 was transferred to the Named Hospital #1 for evaluation of a Fall.

13. Review of the medical record review revealed Patient #19 was admitted on 12/22/2022 with a diagnosis of Dementia.

Review of the EMS transport log 1/16/2023 revealed Patient #19 was transferred to the Named Hospital #1 for a abnormal lab results.

In an interview in the group therapy room on 3/13/2023 at 10:45, the Director of Nursing (DON) was asked do you sign your patient out on a log when they are transferred out and if so what is that log called. The DON stated, "...Yes we sign them out on a log and it is called the transfer log."