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Based on interview and documentation review the Hospital failed to ensure that all issues identified during an investigation were addressed with a corrective action plan.

Findings included:

Medical record documentation dated 1/20/11 indicated Patient #1 was brought to the Hospital by ambulance and was diagnoses with a partial SBO.

The physician who examined Patient #1 in the ED on 1/20/11 (ED Physician) was interviewed on 2/15/11 at 11:50 A.M. and Patient #1's documentation was reviewed. The ED Physician said and documentation indicated when he/she examined Patient #1, Patient #1 was alert and oriented, without evidence of trauma, and denied changes in vision, dizziness, or a headache.

Medical record documentation dated 1/20/11 to 1/23/11 indicated Patient #1 remained alert and oriented. Patient #1 was assessed for fall risk and the assessments, except for assessments performed during the evening shift on 1/22/11 and 1/23/11 indicated Patient #1 denied a history of falls and was at low risk for falls. The 1/22/11 and 1/23/11 evening assessments indicated Patient #1 reported falling prior to admission was at high risk for falls. Documentation indicated that fall interventions were in place and even when Patient #1 was considered to be at low risk for falls. A bed alarm activated for all but 2 shifts; the day shift on 1/22/11 and 1/23/11, when Patient #1 was assessed to be independent with transfers and ambulation.

The nurse assigned to Patient during the evening shift on 1/22/11 and 1/23/11 (Nurse #3) was interviewed on 2/15/11 at 3:35 P.M. and his/her documentation was reviewed. Nurse #3 said that on both days a fall risk assessment was completed and with each assessment Patient #1 was asked if he/she had a history of falls. Nurse #3 said Patient #1, who was alert and oriented, reported he/she had lost his/her balance a couple of days prior to admission and there were no injuries because he/she caught herself during the fall. Nurse #3 said there were no obvious bruises and Patient #1 denied dizziness or a headache.

The nurse (Nurse #4) assigned to Patient #1 /22-23/11 and 1/23-24/11 on the night shifts was interviewed on 2/16/11 at 7:40 A.M. Nurse #4 said Patient #1 was alert and oriented at the beginning of the shift, had been using the commode frequently, and reported being tired of having to get up so frequently. Nurse #4 said he/she made sure the call light was in place, the bed alarm was on, and all other fall prevention interventions were in place. Nurse #4 noted Patient #1 had a small bruise on the right upper eyelid that was not there the previous night. Nurse #4 said he/she did not ask about the bruise, did not make out an incident report, and did not report the bruise to anyone. Nurse #4 said Patient #1 denied pain, dizziness, or a headache. Nurse #4 said he/she completed a fall risk assessment but did not ask Patient #1 about a fall history (on either night).

Nurse #4 said Patient #1 was up to the commode frequently all shift and was steady on his/her feet. Nurse #4 said a couple of times the alarm sounded when Patient #1 went to get up unassisted however; Nurse #4 reached the bedside before Patient #1 got out of bed. Nurse #4 said that around 5:00 A.M., Patient #1 was weaker and complained of nausea that Nurse #4 thought was due to the multiple trips to the commode, frequent stools, and lack of sleep. Nurse #4 said Patient #1 was medicated for nausea and went back to sleep. Nurse #4 said around 6:00 A.M. Patient #1 was very weak with an increased blood pressure and pulse and the covering Hospitalist was notified. Nurse #4 said Patient #1 was already receiving continuous intravenous fluids so the Hospitalist told him/her to hold the scheduled 6:00 A.M. laxative. Nurse #4 said Patient #1 was in bed with the alarm on. Nurse #4 said at approximately 6:30 A.M. he/she and CNA #2 went into the room to pull Patient #1 up and Patient #1 had a left facial droop and garbled speech. Nurse #2 said a Code Gray (stroke) Rapid Response was called.

Medical record documentation dated 1/24/11 indicated a head CT scan was performed on Patient #1 per the Stoke Protocol and revealed Patient #1 had a subarachnoid hemorrhage, right cerebral and tentorial hematomas causing a 1 centimeter leftward brain herniation, a possible small right parietal epidural hematoma, bilateral frontal lobe contusions, and a nondisplaced right parietal temporal skull fracture. Patient #1 was intubated and transferred to the Intensive Care Unit. Discussions were held with family regarding Patient #1's poor prognosis and the decision was made to not pursue aggressive measures. Patient #1 expired on 1/25/11.

The Hospital's Chief Medical Officer (CMO) was interviewed throughout the survey. The CMO said he/she conducted a medical record review and determined Patient #1's medical care was appropriate. The CMO said, he/she was not a Neurosurgeon but in his/her opinion, Patient #1's bleed most likely occurred around 6:00 A.M. The CMO said he could not determine when the skull fracture had occurred and could not determine if the bleed was the result of the fracture or the result of a blood vessel bursting. The CMO said because Patient #1 had been on Plavix and a prophylactic dose of Lovenox, there would be increased bleeding if a vessel had burst. The CMO said the fracture occurred in the thinnest part of the skull, there had been no reported falls during hospitalization, and Patient #1 was unreliable regarding information about his/her fall history.

The Risk Manager and the Medical/Surgical Clinical Specialist were interviewed throughout the survey. The Risk Manager said that the investigation could not determine the source of Patient #1's injuries however; opportunities for improvement were identified. The Risk Manager said the investigation determined that not all nurses assigned to Patient #1 asked about fall history as required by the fall risk assessment. The Clinical Specialist said all nurses throughout the Hospital were notified that they were required to ask each patient about his/her fall history at each re-assessment regardless of how many times they had asked the patient (sent via electronic mail and copy provided). The Clinical Specialist said that in addition, anyone identified with a fall history would be noted under a special alert field that carried over from shift to shift and visit to visit and would be visible to each person caring for that patient for assessment consistency. The Risk Manager said the investigation also recognized that Patient #1's bruise had not been documented or reported.

The Hospital did not provide evidence that the lack of a nursing assessment, documentation, incident report, and communication about Patient #1's bruise was addressed through a corrective action plan.

Based on interview and observation the Hospital failed to maintain the cleanliness of floors in the Emergency Department.

Findings included:

A tour of the Emergency Department (ED) was conducted on 2/15/11 with the Risk Manager and the interim Director of the ED present.

During the tour the floors throughout the ED were observed to be soiled and stained.

The Interim Director said the cleanliness of the ED floors was a recognized problem and had been conveyed to the Housekeeping Department however; due to the fact the ED had been very busy lately there had been no identified good time to clean the floors.

During the survey a memo was sent to the Housekeeping Department regarding the condition of the ED floors.