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Based on observation, interview and record review the Quality Assurance Performance Improvement Committee (QAPI) failed to investigate the root cause of a fall and institute measures for improvement for a fall resulting in a fractured bone, hospitalization, surgical intervention, and rehabilitation of 1 (Patient #2), resulting in 2 (Patient #21 and #24) being observed to be at the immediate risk of falling with potential injury, and failed to adequately investigate if carpeted mats were the cause of one patient's fall (Patient #17), resulting in a potential tripping hazard for residents in the facility.

The findings included:

Review of the QAPI quarterly report for June of 2017 shows there had been 9 falls in the month of May 2017, three more falls than in April. 78% of the falls occurred with patients who were on fall precautions. The June QAPI report includes the fall of Patient #2.

1. Patient #2 was a 69 year old male who was admitted to the facility from an acute care hospital on 5/23/17. Patient #2 had been discharged from the hospital with a history of altered mental status.

The "History and Physical" (H&P) dated 5/24/17, documents Patient #2 had a history of alcohol dependency, left and right hip surgeries, tremors, mild cognitive impairment, unsteady gait, vertigo (dizziness or lightheadedness), Osteoarthritis, Degenerative joint disease with fracture, hypertension and insomnia.

Review of the "Nursing Admission Screen and Assessment" shows the admitting nurse identified 6 issues which could have increased Patient #2's likelihood of falling. The admitting nurse underlined Patient #2's antihypertensive and benzodiazepine medications which have the potential to increase the likelihood of falling.
Each of the identified potentials for increased falls are to be added as one point each on the tool.

The admitting nurse placed the patient on fall precautions and documented the patient had a fall assessment score of 3-5 making him at moderate risk for a fall.

Review of Patient #2's "Treatment Care Plan" showed Patient #2 was at risk for falls because he had an unsteady gait and walked with a cane. Two interventions are listed on the treatment plan: the nurse will educate the patient on the fall risk screening process on admission, and will educate the patient on fall risk precautions at the time of implementation.

Review of the fall assessment completed on admission shows the higher level of supervision assessed on the tool was never addressed by the admitting nurse in a nurse's note or by the physician in the H&P. Review of the medical record shows Patient #2 remained at the minimum supervision level of 30 minute checks.

On 5/28/17 at 2:10 p.m., Patient #2 was found on the floor and in his bedroom. The nurse documented Patient #2 told her he fell getting up to turn the air conditioner down. The investigation completed by the facility lists the room being dark as contributing to the patient's fall.

On 8/1/17 at 11:50 a.m., the Risk Manager (RM) said he had not investigated if the night light in the room was working or if the night light was on or off at the time of Patient #2's fall. The RM said the patients room was toward the end of the hall, away from the nurses station which may have contributed to the fall. The RM said the hospital called the facility and reported the patient was incoherent when he arrived at the hospital. The RM said Patient #2 suffered a fractured femur, had surgery, and was sent for rehabilitation when he left the hospital.

On 8/1/17 at 4:15 p.m., the Director of Nurses (DON) said he would expect his nurses to place a resident who scored greater than a 5 on the admitting fall assessment on 1 to 1 observation until the patient could be re-evaluated.

On 8/1/17 at 4:30 p.m., the RM said he had not seen the fall assessment completed on admission for Patient #2. The RM said patients assessed with a score over a 5 on the screening tool are not placed on 1 to 1 observations at the facility.

On 8/2/17 at 11:58 a.m., RN Staff P said she had not considered placing the patient on 1 to 1 observation but she had informed the physician the patient had an unsteady gait.

On 8/2/17 at 12:20 p.m., the Administrator and RM were unable to provide a standard teaching tool for nurses to use for patient education regarding fall precautions at the facility. The Administrator verified there was no instruction on fall precautions in the patient handbook. They were unaware of any handout on fall precautions given out by nurses. The Administrator said if a patient scored greater that a 5 on the fall screening tool he would expect the admitting nurse to use her judgement and decide if the patient needed to be on 15 minute checks or 1 to 1 supervision.

2. On 8/2/17 at 10:00 a.m., observed Patient #24 wearing a yellow arm band indicating she was a fall risk. Patient #24 said she had just arrived at the facility and she was still "coming down." While speaking with the patient she was observed to lose her balance and stumble. The Director of QAPI was observed to reach out and attempt to steady the patient.

On 8/2/17 at 10:05 a.m., drops of clear fluid were observed ten feet in front of the nurses station and extending down the hall approximately 200 to 300 feet. The drops of fluid were observed to be 1 to 2 feet apart. Observed Patient #24 swaying from one side of the hall to the other, unsteady on her feet, walking towards the spill near the nurses station while the Director of QAPI and RN Staff Q cleaned the floor.

On 8/2/17 at 10:10 a.m., Patient #24's Fall Assessment which was completed on 8/1/17 showed Patient #24 had a fall assessment score of five. The Director of QAPI verified Patient #24 was on the minimum supervision of 30 minute checks. The Director of QAPI said Patient #24 should have been placed on 15 minute checks due to her fall assessment.

Review of the "Treatment Care Plan" for fall precautions for Patient #24 shows two interventions: 1. The nurse will provide patient education on fall risk precautions at the time of implementation. 2. The nurse will educate patient on the fall risk screening process on admission.

On 8/2/17 at 10:15 a.m., RN Staff Q read the first identifier of potential fall listed on the form which is a new diagnosis of a cardiac arrhythmia. Staff Q flipped the chart to an Electrocardiogram completed at 10:00 p.m., on 8/1/17. Staff Q said Patient #24 had a heart rate of 54. Staff Q said because Patient #24 had Bradacardia (slow heart rate) she was going to change the assessment to check off that patient had a new diagnosis of a cardiac arrhythmia. Observed Staff Q add to the identifiers of potential falls as 5+1=6. Staff Q said there is no difference between a score of 5 and 6. Staff Q said she would place the patient on fall precautions. Staff Q did not say she would increase the level of supervision for Patient #24.

The Director of QAPI verified with RN Staff Q she had increased the fall assessment score of Patient #24 and was not going to place the patient on one to one observation. The Director of QAPI told Staff Q Patient #24 needed to be placed on one to one supervision. Staff Q told the Director of QAPI she was not aware the patient needed to be placed on one to one supervision.

On 8/2/17 at approximately 10:30 a.m., the administrator verified Patient #24 was a high risk for falling. The Administrator said Patient #24 had been evaluated at the hospital on 8/1/17 with an ankle injury. The Administrator said Patient #24 had refused a foot brace (Boot) ordered at the hospital to stabilize her ankle.

3. On 8/1/17 at 10:45 a.m., Patient #21 was observed standing in the designated smoking area of the facility. He did not have a yellow wrist band indicating he was a fall risk. The patient said when he had first arrived at the facility the staff thought he was withdrawing from alcohol so they had placed him on fall precautions. He said staff had since removed him from fall precautions. Patient #21 said he had had a seizure prior to coming into the facility. He said he had fallen, hit his head and was hospitalized.

Review of Patient #21's admission fall screening dated 7/27/17 shows the patient scored a 3 making him a fall risk due to history of seizure and fall and medications he was currently taking. The form shows the admitting nurse checked off fall precautions initiated. The nurse did not check off a yellow wrist band was placed on the patient, or staff were notified of the patient's condition.

Review of Nursing Admission Assessment showed the admitting nurse did not include fall prevention as an issue. The nursing flowsheet did not include fall precautions from 7/27/17 through 7/31/17. On 7/28/17 on the 7 a.m., shift RN Staff S documented Patient #21 was on fall precautions and then crossed it out and initialed the error.

On 8/1/17 at approximately 10:50 a.m., RN Staff S said he was not aware Patient #21 was on fall precautions. RN Staff S verified because of Patient #21's admission assessment he should be on fall precautions. RN Staff S said once one of the nurses failed to check off the patient was on fall precautions all the other nurses would follow what the previous nurse had checked off. Staff S said this is how the patient was not checked off by any other nurse as being on fall precautions.

On 8/1/17 at approximately 11:10 a.m., the Director of QAPI said she was unable to find any documentation Patient #21 had been taken off fall precautions. The Director of QAPI verified due to the assessment of the potential risk Patient #21 should be on fall precautions.

4. Review of the fall incident dated 5/30/17 showed Patient #17 had tripped over a carpeted area in front of the nursing station.

On 7/31/17 at approximately 3:30 p.m., the Director of QAPI said due to the water spills while medications were being administered carpeted mats had been placed in the front of all areas were medications were administered in the facility.

On 8/1/17 at 8:40 a.m., while touring the 200 unit of the facility with the Director of QAPI no mats were observed in either of the two areas where nurses administer medications to the patients.

On 8/1/17 at 8:55 a.m., a mat with a large crimp was observed in the front of the window where nurses administer medications. Observed the Director of QAPI place her foot over the crimp and attempt, unsuccessfully, to smooth the area out. The Director of QAPI said, "I guess I will just stay here all day."

On 8/1/17 at 11:00 a.m., the Risk Manager verified Patient #17 had tripped over the mat in the front of the nursing station. The Risk Manager said he had not investigated how Patient #17 had tripped over the area or checked to see if the carpeted area the patient had tripped over had been crimped.

Based on record review, interview and observation, the Quality Assurance Performance Improvement Committee (QAPI) failed to evaluate the interventions and the policies implemented for fall precautions resulting in the potential for patient falls.

The findings included:

1. On 7/31/17 at 11:00 a.m., the Administrator said the hospital has a policy called "Code Yellow." If there was a large spill that cannot be handled by one staff member a code yellow was called by announcing over the intercom of the hospital three times code yellow. This was to alert staff to a large spill that needs to be cleaned immediately.

On 8/1/17 at 10:00 a.m., while touring with The Director of QAPI, observed a spill of brown fluid in a trail approximately 10 to 20 feet in the atrium of the facility. The Director of QAPI had continued to walk away from the spill and had to be brought back to the area. Observed the Director of QAPI tell a staff member to call a code yellow. A patient was observed to get a caution cone and place it over the area of the spill. After several minutes the area was cleaned by housekeeping. No code yellow was ever noted to be called over the intercom.

On 8/1/17 at 12:09 p.m., the Director of QAPI verified that she had called a code yellow and that staff had not responded by calling the code yellow three times over the intercom. The Director of QAPI was not able to say why the code yellow had not been called.

On 8/1/17 at 12:29 p.m., behavioral technician Staff R said he had not called a code yellow because he was able to get housekeeping to come to the area. Staff R said, "Code Yellow means a spill."

On 8/1/17 at 12:31 p.m., the Director of Housekeeping said the Code yellow should be called to alert all staff that there was a large spill in the building. The Director of Housekeeping said he was told by his supervisor to no longer call a Code yellow over the intercom. He said they were supposed to use the radio to call a code yellow. He said a code yellow had not been called over the intercom for two or three months.

On 8/2/17 at 10:00 a.m., Patient #24 was observed ambulating in the atrium of the facility. The patient was observed with a yellow arm band indicating she was a fall risk. Patient #24 said she had just arrived at the facility and she was still coming down. While speaking with the patient she was observed to lose her balance and stumble. The Director of QAPI was observed to reach out and attempt to steady the patient.

On 8/2/17 at 10:05 a.m., observed drops of clear fluid from ten feet in before reaching the nurses station and extending down the hall approximately 200 to 300 feet. The drops of fluid were observed to be 1 to 2 feet apart. No Code yellow was heard over the intercom. It took 5 to 10 minutes for the area to be wiped up by RN Staff Q and the Director of QAPI.

On 8/2/17 at 3:30 p.m., the Administrator said if staff see a large spill they are to call a code yellow over the intercom three times.

2. On 7/31/17 at approximately 11:10 a.m., the Administrator said the hospital had placed a program of "Keep a Lid on It" to remind patients to keep lids on their drinks to reduce spills and prevent falls. He said signs are placed throughout the facility to remind patients to keep a lid on drinks.

On 8/1/17 at 9:35 a.m., Patient #23 was observed in the open area in front of the dining room with a yellow wristband on indicating he was a fall risk. Patient #23 was carrying a coffee cup with a lid. The lid was covered in coffee and the cup was overfilled. Observed the patient spilling liquid from the cup as he ambulated in the area. The patient verified he had been told by staff that he was on fall precautions. Patient #23 said staff had not instructed him on any interventions that would prevent him from falling other than he was to wear the armband.

Based on observation, interview and record review, the Quality Assurance Performance Improvement Committee (QAPI) failed to ensure adverse incidents were recognized and reported, and failed to ensure staff were trained in assessing the level of supervision needed for patients with high fall risk, and failed to ensure staff trained were in assessing and implementing initial fall risk protocols for 4 (Staff P, Q, S and Risk Manager) of 7 staff interviewed.

The findings included:

1. Patient #2 is a 69 year old male who was admitted to the facility from an acute care hospital on 5/23/17. Patient #2 had been discharge from the hospital with a history of altered mental status.

According to the "History and Physical" (H&P) dated 5/24/17 Patient #2 had a history of alcohol dependency, left and right hip surgeries, tremors, mild cognitive impairment, unsteady gait, vertigo (dizziness or lightheadedness), Osteoarthritis, Degenerative joint disease with fracture, hypertension, and insomnia.

Review of the "Nursing Admission Screen and Assessment" shows the admitting nurse made an "X" indicating 6 identifying issues which could have increased Patient #2's likelihood of falling. The nurse identified: complicated withdrawal symptoms, patient unsteady on his feet, changes in mental status, seizure, falls, and changes in functional status. The last identifier on the list that could be counted is additional medications ordered. The admitting nurse underlined two of the medications included in the list of medications counted as a potential to increase the likelihood of falling: Antihypertensive, and Benzodiazepines. Each of the identified potentials for increased falls are to be added as one point each on the tool. Making Patient #2's fall assessment score 7.

The tool shows Patient #2 had a fall risk score over 5 making him a high risk for falls, and according to the tool, "Potential 1 to 1 observations". The admitting nurse documented the patient's score was 3-5 making him a moderate risk for a fall and placed the patient on fall precautions.

Review of Patient #2's "Treatment Care Plan" shows Patient #2 was at risk for fall because he had an unsteady gait and walked with a cane. Two interventions are listed on the treatment plan: The nurse will provide education on fall risk precautions at the time of implementation and nurse will educate patient on the fall risk screening process on admission.

Review of the fall assessment completed on admission shows Patient #2 was oriented to person and place only on admission. The higher level of supervision assessed on the tool is never addressed by the admitting nurse in a nurse's note or by the physician in the H&P. Review of the medical record shows Patient #2 remained at the minimum supervision level of 30 minute checks.

On 5/28/17 at 2:10 p.m., Patient #2 was found on the floor and in his bedroom. The nurse documented Patient #2 told her he fell getting up to turn the air conditioner down. The investigation completed by the facility lists the room being dark as contributing to the patient's fall.

On 8/1/17 at 11:50 a.m., the Risk Manager (RM) said he had not investigated if the night light in the room was working or if the night light was on or off at the time of Patient #2's fall. The RM said he had discovered that one of the factors that could have contributed to the patient's fall is his room was toward the end of the hall and away from the nurses station. The RM said the hospital had called and the patient was incoherent when he arrived at the hospital. The RM said Patient #2 suffered a fractured femur and had surgery and was sent for rehabilitation when he left the hospital.

On 8/1/17 at 4:15 p.m., the Director of Nurses (DON) said he would expect his nurses to place a resident who scored greater than a 5 on the admitting fall assessment on 1 to 1 observation until the patient could be reevaluated.

On 8/1/17 at 4:30 p.m., the RM said he had not seen the fall assessment completed on admission for Patient #2. The RM said he did not agree with the DON, that patients assessed over a 5 on the screening are to be placed on 1 to 1 observations. He said it was not done at the facility.

On 8/2/17 at 11:58 a.m., RN, Staff P said if she had a patient with a high risk for falls she would ambulate with the patient when he was going to lunch to ensure the patient's safety. RN Staff P said she would not include this intervention in the patient's care plan. RN Staff P verified she scored Patient #2 with a score of 7 on his admission and placed the patient on fall precautions. She said she had not considered placing the patient on 1 to 1 observation but that she had informed the physician the patient had an unsteady gait.

On 8/1/17 at 11:50 a.m., the Risk Manager said he was not aware a fractured bone was reportable as a adverse incident. He said he had not had a password to report incidents for a couple of months. He said he did not think there was a place on the AHCA incident reporting site to report fractured bones.

Review of the AHCA incident reporting system (AIRS) website shows on page 6 in the 5th box a fractured bone can be reported.

2. On 8/2/17 at 10:00 a.m., Patient #24 was observed ambulating in the atrium of the facility. The patient was observed with a yellow arm band indicating she was a fall risk. While interviewing the Patient #24 she was observed to hesitate and pause when being questioned. Patient #24 said she had just arrived at the facility and she was still coming down. While speaking with the patient she was observed to lose her balance and stumble. The Director of QAPI was observed to reach out and attempt to steady the patient.

On 8/2/17 at 10:05 a.m., drops of clear fluid was observed from ten feet in before reaching the nurses station and extending down the hall approximately 200 to 300 feet. Observed the drops of fluid to be 1 to 2 feet apart. This fluid spill was brought to the attention of the Director of QAPI. The Director of QAPI and RN Staff Q began cleaning up the large spill while Patient #24 was observed to pass both staff members and go down the hall where the spill was extending from the nurses station. Observed Patient #24 to be unsteady on her feet, swaying from one side of the hall to the next.

Review of the "Treatment Care Plan" for fall precautions for Patient #24 shows two interventions: 1. The nurse will provide patient education on fall risk precautions at the time of implementation. 2. The nurse will educate patient on the fall risk screening process on admission.

Review of the "Treatment Care Plan" for fall precautions for Patient #24 shows two interventions: 1. The nurse will provide patient education on fall risk precautions at the time of implementation. 2. The nurse will educate patient on the fall risk screening process on admission.

On 8/2/17 at 10:10 a.m.. Patient #24's Fall Assessment which was completed on 8/1/17 showed Patient #24 had a fall assessment score of 5. The Director of QAPI verified Patient #24 was on the minimum supervision of 30 minute checks. The Director of QAPI said Patient #24 should have been placed on 15 minute checks due to her fall assessment.

On 8/2/17 at 10:15 a.m., Staff Q said there is no difference between a score of 5 and 6.

Review of the Nursing Admission Screen and Assessment revealed The Falls Assessment codes risk on a scale of 0 to 5, with 0 indicating no risk, 1-2 (low risk-screen daily), 3-5 (moderate risk-indicate fall precautions ), and over 5 (high risk=potential for 1 to 1 observations). Under Precautions taken is a list of 8 possible fall precautions, but the list does not specify which precautions should be taken based on the assessed risk.

The Director of QAPI verified with RN Staff Q that she had increased the fall assessment score of Patient #24 and was not going to place the patient on one to one observation. The Director of QAPI told RN Staff Q patient #24 needed to be placed on one to one. Staff Q said to the Director of QAPI she was not aware the patient needed to be placed on one to one.

3. On 8/1/17 at 10:45 a.m. Patient #21 was observed standing in the designated smoking area of the facility. He did not have a yellow wrist band indicating he was a fall risk. The patient said when he had first arrived at the facility the staff thought he was withdrawing from alcohol so they had placed him on fall precautions. He said staff had since removed him from being on fall precautions. Patient #21 said he had had a seizure prior to coming into the facility. He said he had fallen and hit his head and was hospitalized.

Review of Patient #21's admission fall screen dated 7/27/17 shows the patient scored a 3 making him a fall risk due to history of seizure and fall and medications he was currently taking. The form shows the admitting nurse checked off fall precautions initiated. The nurse did not check off a yellow wrist band was placed on the patient, or staff were notified of the patient's condition.

Review of Nursing Admission Assessment shows the admitting nurse did not include fall prevention as a management issue. The Nursing flowsheet does not include fall precautions from 7/27/17 through 7/31/17. On 7/28/17 on the 7 a.m. shift Staff S, RN, documented Patient #21 was on fall precautions and then crossed it out and initialed the error.

On 8/1/17 at approximately 10:50 a.m., RN Staff S said he was not aware Patient #21 was on fall precautions. Staff S verified because of patient #21's admission assessment he should be on fall precautions. Staff S said once one of the nurse failed to check off the patient was on fall precautions all the other nurses would follow what the previous nurse had checked off. RN Staff S said this is how the patient was not checked off by any other nurse as being on fall precautions.

On 8/1/17 at approximately 11:10 a.m., the Director of QAPI said she was unable to find any documentation that Patient #21 had been taken off fall precautions. The Director of QAPI verified due to the assessment of the potential risk Patient #21 should be on fall precautions.

4. Review of the "Licensed Staff Competency" for RN Staff P, dated 6/15/17, showed no documentation Staff P had been instructed in the "Nursing Admission Screen Assessment: Fall Screen." According to the staff roster RN Staff P was hired 6/18/00.

Review of the "Licensed Staff Competency" for RN Staff Q, dated 3/30/17 showed no documentation the Staff Q had been instructed in the "Nursing Admission Screen Assessment: Fall Screen." According to the staff roster RN Staff Q's hire date was 7/26/12.

On 8/2/17 at 1:29 p.m., the Clinical Program Director said she ensured all new nursing hires were in-serviced in using the admission fall screen tool. She said she instructed new hires, if the fall screen score was greater than five to call the physician and place the patient on one to one observations. The Clinical Program Director said the assessment tool has been in use for five to six years.

The Clinical Program Director said she had not instructed either RN Staff P or RN Staff Q in the use of the fall assessment tool because both staff members had been working at the facility before she had arrived. The Clinical Program Director said the tool was only reviewed at the initial hire orientation of staff members.