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Based on medical record review and staff interview, the facility failed to ensure the patient's representative was informed of his or her health status for one of ten patients reviewed (Patient #1). This could affect all patients receiving services from this facility. The patient census was 43.

Findings include:

Review of Patient #1's medical record revealed the patient was admitted on 09/27/21. The adult psychosocial assessment dated 09/28/21 revealed the patient had a son and a wife and both were listed as Power of Attorney.

Review of an incident report involving Patient #1 and dated 10/09/21 at 3:15 PM revealed the patientwas noted to have been on the mattress on the floor and refusing to get up, grimacing and with decreased level of consciousness. On further assessment, Patient #1 was unable to tolerate vital sign collection due to agitation. Patient #1 was alert to self but rigid and shaky. The medical doctor and psychiatrist on call were contacted and a new order was given to send Patient #1 to the emergency department (ED) for further assessment. 911 was called and Patient #1 was transferred to the hospital. The incident report noted that family was contacted, but unreachable. It was not documented who the facility attempted to contact.

There was no documentation the facility attempted to contact either the patient's son or wife after the initial attempt.

The patient's medical record from the ED visit on 10/09/21 and hospital admission was reviewed. Review of the triage report dated 10/09/21 revealed the patient arrived to the ED at 3:34 PM and has been declining over the last two days. The chief complaint is mental status change. A chest X-ray was obtained on 10/09/21 at 4:03 PM which resulted in left lower lung atelectasis, aspiration pneumonia and pneumothorax. A chest tube was place in the ED. The ED note at 3:57 PM revealed for the skin assessment there was no bruising or rash. The patient was admitted to inpatient at 10:27 PM.

Review of the history and physical revealed the hospitalist saw the patient on 10/09/21 at 11:48 PM. The principal problem is multiple rib fractures involving four or more ribs and the active problem was a pneumothorax.

Interview with Staff A on 11/15/21 at 9:53 AM revealed if a patient had a guardian or activated Health Care POA, staff attempted to contact them after every incident.

This deficiency substantiates Substantial Allegation OH00126680.

Based on medical record review, staff interview, and policy review, the facility failed to ensure nursing staff developed a nursing care plan for each patient that reflects the nursing care to be provided to meet the patient's needs (A396).

Based on medical record review, staff interview, and policy review, the facility failed to ensure nursing staff developed a nursing care plan for each patient that reflects the nursing care to be provided to meet the patient's needs for one of 10 patients reviewed (Patient #1). This could affect all patients receiving services from this facility. The patient census was 43.

Findings include:

Review of the policy and procedure titled, Seizure Precautions, created 07/2013, next review 08/2022, revealed staff will provide interventions to minimize potential of injury and/or anoxia during seizure activity. The potential for seizure activity will be included in the patient's Treatment Plan. The procedure included that the patient observations sheet will indicate "Seizure Precautions," patient room/bed will be located close to the nursing station when possible, information obtained regarding previous seizure activity will be incorporated into the treatment plan to assist in minimizing seizure activity, the patients chart will be flagged stating seizure precautions if known seizure disorders.

The fall prevention and monitoring protocol upon admission to the hospital revealed all patients will be assessed using the Morse Falls Scale and Medication Fall Risk score. Nurses will look at both scales and identify specific areas of risk and ensure measures and interventions are in place to prevent a future fall. Interventions may include non-slip socks or well fitting footwear, fall risk arm band and provider evaluation of medications and if a patient was previously living in an assisted living or skilled nursing facility request information for fall prevention interventions that are utilized at the facility and history of falls to assist the hospital with fall prevention.

Review of the referral information from the nursing home revealed Patient #1 was admitted to a nursing home on 05/13/21. The nurses' notes from the nursing home revealed on 08/10/21 and 08/11/21 the patient was found on the floor in his bedroom at the nursing home. The documentation revealed after the 08/10/21 incident they completed an X-ray where they found the lumbar compression fractures. The referral information also revealed the patient had a history of seizures but there was no indication he had had one recently.

Review of the nursing admission assessment to this facility dated 09/27/21 revealed the patient arrived with his son because he was becoming combative at the skilled nursing facility (SNF) where he currently lived. The patient presented confused and oriented to name only. Mumbling and only able to understand a few words.

The admission summary sheet revealed the admitting diagnosis was major depressive disorder (MDD). The patient also had a history of seizures and was on anti-seizure medication. The nutritional screen dated 09/27/21 revealed the patient was six foot four inches and weighed 263 pounds. The psychosocial note reported the patient had aggression and agitation that was unprovoked lately. He had been combative with care historically but it had escalated and gotten progressively worse.

Review of the Morse Fall Scale revealed the patient was assessed as a moderate risk for falls with a score of 30. Review of the Medication Fall Risk Score revealed the patient was assessed as a 23 and considered high risk for falls. This was confirmed in an interview with Staff A on 11/10/21 at 5:58 PM. Staff A also stated that even if the patient was only assessed as high risk on one of these assessments, then a patient was considered to be high risk which would apply in the case of this patient.

Review of the patient's record revealed that during the patient's stay, the provider did put a fall matt on the floor beside the patient's bed and a mattress on the floor, but this was not included as part of the treatment plan.

The master treatment plan only listed the diagnosis of seizure activity as deferred, but did include to stabilize mood with Depakote and Seroquel, monitoring for safety, suicidal risk assessment and 15 minute checks. The patient 15 minute observation sheets from 09/28/21 through transfer to the emergency department (ED) on 10/09/21 were not marked as the patient having seizure precautions or fall precautions where it was was listed on the observation sheets.

Review of the psychiatric evaluation dated 09/28/21 revealed current medication included Imuran (immunosuppressive) 50 milligrams (mg) daily, Aricept 20 mg daily, Proscar 2.5 mg two times a day, Lamictal (anti-seizure) 25 mg two times a day, Keppra (anticonvulsant) 750 mg two times a day, Melatonin (sleep aid) six mg at night, Namenda (for dementia) 10 mg once a day, Seroquel (antipsychotic) 50 mg once a day and Effexor XL (anti-depressant) 150 mg a day.

Review of the social worker (SW) progress notes revealed on 10/07/21 the SW tried to call the power of attorney (POA) because nursing reported the patient had been laying on the floor all day and refusing to get up. The SW also asked the behavioral health technician (BHT) to help lift the patient so he would not be cold on the floor. Son/POA reported he did this before and will usually get up for sweets. The patient would not allow the BHT to help and began cursing at her when she touched his arm. SW gave the patient another blanket to keep warm after the BHT covered him in a sheet and blanket from his bed and readjusted his pillow behind his head. SW stayed to support the patient and spoke with him and rubbed his back until he became less agitated, stopped moaning and kicking the side of his bed, and closed his eyes to rest.

Review of the nursing reassessment notes revealed on 10/04/21 the patient slid out of his wheelchair while dozing off and on in wheelchair and sat on the floor; 10/06/21 continues to put self on floor; 10/07/21 laying on floor refusing to get up; 10/08/21 puts self on floor; 10/09/21 day shift lay on floor and refuses to get up for medications or group and then at 2:45 PM found on the floor, level of consciousness decreased, shaking and grimacing. The physician was notified and the patient was sent to the emergency department (ED).

Review of the incident report dated 10/09/21 revealed the patient was noted to have been on the mattress on the floor and refusing to get up, grimacing with decrease level of consciousness. On further assessment, the patient was unable to tolerate vital sign collection due to agitation. The patient was alert to self but rigid and shaky. The medical doctor and psychiatrist on call was contacted and a new order given to send the patient to the ED for further assessment. 911 was called and the patient transferred to the hospital. Family contacted but unreachable.

The patient's medical record from the ED visit on 10/09/21 and hospital admission was obtained for review. Review of the triage report dated 10/09/21 revealed the patient arrived to the ED at 3:34 PM and has been declining over the last two days. The chief complaint is mental status change. A chest X-ray was obtained on 10/09/21 at 4:03 PM which resulted in left lower lung atelectasis, aspiration pneumonia and pneumothorax. A chest tube was place in the ED.

Review of the history and physical revealed the hospitalist saw the patient on 10/09/21 at 11:48 PM. The principal problem is multiple rib fractures involving four or more ribs and the active problem was a pneumothorax.

Interview with Staff B on 10/20/21 at 1:32 PM revealed the day the patient went to the hospital he was lying on a mattress on the floor on his side. That morning he gave the patient his medications in yogurt. He tried to get the patient's blood pressure and he kept swinging his arm and it gave him an error. This nurse and two BHT's were cleaning him up because he had a bowel movement. He soiled the mattress so staff had to get a clean mattress. The patient was different this day. Previously he could eat, walk around and open his eyes. But that morning they went to his room he did not seem okay. He had facial grimacing and had a hard time opening his eyes. The patient was always combative when staff would change his incontinent pad. He liked to be left alone. He was still combative the morning he was not himself. He was resistive to care and would not let staff take his brief off. They cleaned him up and put a clean brief on him. Then staff were able to get him back in bed and used a bed sheet to lift him off of the soiled mattress. Staff B did not know how he fractured his ribs. There was no report of any injuries.

Interview with Staff F on 10/22/21 at 10:53 AM revealed he was on call and saw the patient on Saturday morning (10/09/21) and had only seen the patient one time. He received a call on Saturday afternoon and was told by nursing that the patient may have had an unwitnessed fall and gave orders to transfer him to the ED for evaluation. When the physician came to this facility he was given the report that the patient was admitted to the hospital with fractured ribs. When he received the report it made him think the patient may have had an unwitnessed fall. The patient was known to put himself on the floor. He was also known to slide himself down out of a wheelchair in a controlled manner. Staff F revealed he had seen him do this and staff would help him up without issues. The staff was immediately on top of this. Staff F revealed when he was given the report the patient was on the floor, he may have assumed the patient had an unwitnessed fall.

Interview with the Staff A by telephone the afternoon of 11/10/21 revealed the physician would write orders for interventions for the patient in regard to falls if he felt it was necessary.

Interview with Staff A on 11/15/21 at 10:45 AM revealed in the Root Cause Analysis summary there were no fall or seizure precautions ordered but there were some interventions in place, like a fall matt, even though there was no order for fall or seizure precautions. Staff A also confirmed that, yes, because there were no fall or seizure precautions ordered, the patient round observation sheets would not have those precautions selected/marked.

This deficiency substantiates Substantial Allegation OH00126680.