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Based on observation, document review, and interview it was determined that the hospital failed to comply with the Condition of Participation 42 CFR 482.23, Nursing Services.

Findings include:

1. The hospital failed to ensure that physician's order were followed and failed to assess/re-assess for fall risks and provide fall interventions in accordance to hospital's policy. See deficiency cited A-0395 A.

A. Based on observation, document review and interview, it was determined that for 2 of 4 (Pt. #17 and Pt. #25) onreviewed for high fall-risk, the hospital failed to ensure that physician's order were followed and failed to assess/re-assess for fall risks and provide fall interventions in accordance to hospital's policy.

Findings include:

1. On 09/19/2023 between 11:50 AM - 1:30 PM, an observational tour of the 6th Floor Adult Oncology Unit was conducted.

- At approximately 12:29 PM, Pt. #17 in Room #615-2 was observed sitting on a chair beside (Pt. #17) bed and having lunch. Pt. #17's room whiteboard did not indicate fall precautions sticker, the rounding times were left blank. Pt. #17 stated that Pt. #17 came to the hospital because, Pt. #17's left foot was infected, and toes were amputated, and had some challenges while moving from bed to chair and while walking. Pt. #17 stated that Pt. #17 uses walker while walking and takes one-person to assist.

2. On 09/19/2023, the clinical record for Pt. #17 was reviewed. Pt. #17 came to the emergency department (ED) on 09/11/2023 at 2:11 PM, with a chief complaint of left foot pain. The clinical record included:

-A physician's order dated 09/12/2023 at 7:00 PM, indicated, "Place patient under fall precautions, PT/OT [physical therapy and occupational therapy] to evaluate the patient."

-The occupational therapist evaluation note dated 09/17/2023 at 1:51 PM, indicated, " ...weakness, decreased endurance, decreased strength, impaired balance, weight bearing ...functional limitations, decreased ability to complete lower body dressing, bathing, toileting, toilet transfers ...high fall risk and impaired cognition ..."

-The physician progress note dated 09/18/2023 at 11:30 AM, included, "[Pt. #17] had a rapid response today, per patient, [Pt. #17] was trying to reach out for the water to drink when [Pt. #17] felt dizzy and fell. Fall was witnessed and [Pt. #17] didn't hit [Pt. #17] head. A Rapid response call was made immediately."

- The Nursing progress note dated 09/18/2023 at 8:10 PM, included, "...[Pt. #17] had an episode with altered mental status, rapid called, [Pt. #17] regained mentation in 3 minutes ...physician placed orders for iv [intravenous] fluids and labs post rapid call."

- The fall risk assessment flowsheet from 09/11/2023 to 09/19/2023 was reviewed and indicated that, Pt. #17's fall risk assessment scores were missing for several days as follows: 09/11/2023, 09/13/2023, 09/14/2023, 09/15/2023, 09/18/2023 and 09/19/2023.

There were inconsistencies with the fall risk assessment scores that were done as follows: on 09/12/2023 at 2:15 PM -Morse Fall Risk Score 15 (no risk); on 09/16/2023 at 9:00 AM - Morse Fall Risk Score 20 (no risk); on 09/16/2023 at 9:10 PM - Morse Fall Risk Score 15 After patient fall on 09/18/2023, there were no modifications in planned/implemented fall preventions strategies.

3. On 09/22/2023 at 11:00 AM, the clinical record for Pt. #25 was reviewed. Pt. 25 came to the emergency department on 09/16/2023 at 11:19 AM, with a chief complaint of abdominal pain. Pt. #25 was admitted to the 6th floor Oncology Unit, with a diagnosis of anemia. Pt. #25 clinical record included the following:

-The inpatient physician progress note dated 09/19/2023 at 7:10 AM, included, " ...RRT x2 [rapid response team called two times] Rapid called at 00:22 for agitation during blood transfusion, was given 1 unit RBC [red blood cells] ...Rapid called at 5:00 AM for melena x3 [blood in the stool] and calling while using bedside commode fell ...pt. [pt. #25] did not hit head..."

-The nurse progress note dated 09/19/2023 at 5:03 AM, included, " ...Met patient on blood transfusion ...no reaction observed ...later patient [Pt. 25] called sob [shortness of breath] with saturation of 100% [percent] and was restless stating "My abdomen is paining me and I want to poop" ...patient trying to use commode fell and sitter witnessed fall, held the head from hitting the floor, physician notified of the fall ..."

-The nursing fall risk assessment flowsheet was reviewed, on 09/16/2023, there were no morse fall risk assessment scores and fall prevention interventions documented in Pt. #25's chart for 09/17/2023, 09/18/2023, 09/19/2023 until 5:00 AM.

4. On 09/20/2023, the hospital's policy titled, "Fall: Patient, Risk Assessment, Prevention and Management" dated 09/2023 was reviewed and indicated, "A fall risk assessment is completed upon an initial patient assessment ...during the admission process to a unit ...thereafter each shift should perform an assessment ...when patient's condition changes ...assess patient and then document in the medical record for the presence of fall risk factors using the Morse Fall Scale (MFS) for adults (18 years of age and above) ...No Risk (0-24) Green on stoplight ...Low Risk (25 -50 points) Yellow on stoplight ...High Risk (greater than 51 points) Red on Stoplight sign ...Management of a Fall Patient: Immediately post-fall perform the following: ...Assess the patient ...notify the physician of all events and findings ...notify the unit-based leadership ...assess need for modification (s) in planned/implemented fall preventions strategies ...frequent rounding, bed chair alarm or other protective equipment or constant observer ...report fall in electronic patient safety event reporting system ...post fall huddle ...complete the form ...and send to the unit-based leadership ...patient specific interventions based on risk score ..."

5. On 09/20/2023, the job description/Performance Appraisal and Competency Evaluation of Staff Nurse or Staff Nurse Registry dated 05/16/2023, was reviewed and indicated, " ...Implements physician and nursing orders as appropriate involving patient ..."

6. On 09/21/2023 at approximately 9:40 AM, an interview was conducted with the Chief Nurse Officer (E #2). E #2 stated that staff are required to do the fall risk assessment every 12 hours. E #2 stated the patient on fall precautions signage should have been placed on the door and written on the whiteboard at the bedside, so all staff are aware to follow fall precautions.

7. On 09/22/2023 at 12:30 PM, the Oncology Unit Registered Nurse (E #33) who took care of patient (Pt. #25) on 09/19/2023, was interviewed. E #33 stated that there was an RRT called for Pt. #25 on 09/19/2023 at 12:00 midnight, because patient was restless. E #33 stated that Pt. #25 had diarrhea, was using the bedside commode and fell on the floor while sitter was at the bedside. E #33 stated that patient (Pt. #25) had a fall but did not hit the head on the floor. E #33 stated that the patient fall score assessment must be done upon admission and every shift. E #33 stated that E #33 does not recall if patient (Pt. #25) was on any fall precautions.


B. Based on observation, document review and interview, it was determined that for 1 of 1 (Pt. #17) observed for bedside glucose testing, the hospital failed to ensure that blood glucose testing was completed per physician's orders.

Findings include:

1. On 09/19/2023 between 11:50 AM - 1:30 PM, an observational tour of the 6th Floor Adult Oncology Unit was conducted. During the tour the following was observed:

-During the tour at approximately 12:29 PM, Pt. #17 in Room #615-2 was observed sitting on a chair beside (Pt. #17) bed and having lunch. Pt. #17 had already finished eating half of the bread roll and twenty-five (25) percent of the rice and beans. Pt. #17's room whiteboard indicated bedside blood glucose monitoring before lunch was not done. Pt. #17 stated that the E #7 (certified nurse assistant/CNA) had not done Pt. #17's blood glucose testing.

2. On 09/19/2023, the clinical record for Pt. #17 was reviewed. Pt. #17 came to the emergency department (ED) on 09/11/2023 at 2:11 PM, with a chief complaint of left foot pain. The clinical record included:

- A physician's order dated 09/12/2023 at 9:00 AM, included, "Perform bedside blood glucose testing AC and HS [before meals and at bed time] 4 times daily ...

3. On 09/20/2023, the job description of Certified Nursing Assistant dated 11/09, was reviewed and indicated, " ...The Certified Nursing Assistant (CNA) performs a variety of functions in the clinical setting ...provide direct patient care ...collaborate with and works under the direction of the registered nurse to provide appropriate and safe patient care."

4. On 09/21/2023, the job description of the Agency Contracted Nurse, date unknown, was reviewed and included, " ...Performs evaluation of patients in an accurate and timely manner ...documentation in an accurate and timely fashion ...supervises and coordinates services for assigned patients ...communicates promptly ...other members of the health care team ...evaluates the effectiveness and outcome of care ...provides instruction and supervision of Certified Nursing Assistants ..."

5. On 09/19/2023, at approximately 12:45 PM, the Certified Nurse Assistant (CNA) (E #7), was interviewed. E #7 stated that she forgot to do the glucose testing for Pt. #17. E #7 stated that she could not do bedside glucose testing for six (6) patients that were assigned to E #7, because she was transferring patients to another unit.

6. On 09/19/2023, at approximately 12:50 PM, the Agency Nurse (E #5) was interviewed. E #5 stated that the bedside glucose testing should have been done for all the assigned patients. E#5 stated that now that patient (Pt. #17) had already ate almost more than half of (Pt. #17) lunch the glucose test results would be inaccurate. E #5 stated that she does not know the blood glucose level for Pt. #17 since she (E #5) was at lunch. E #5 stated that E #5 had not given the insulin to any patient since she was not aware of the bedside glucose levels.

7. On 09/19/2023, at approximately 12:55 PM, the Nurse Director (E #8) was interviewed. E #8 stated that the CNA (E #7) should have either notified to another CNA on the unit or to the charge nurse or the assigned agency nurse (E #5) of the patient. E #8 stated that it is not acceptable not to do bedside glucose testing on patients prior to them having their lunch and providing patient (Pt. #17) with insulin as ordered by the physician.