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Based on record review, interview and policy review, the facility failed to ensure four side rails were not utilized for a patient at high risk for falls and failed to ensure patients using restraints were assessed every two hours.

See A154 and A175.

Based on record review, interview and policy review, the facility failed to ensure four side rails were not used as a restraint for a patient assessed at high risk for falls. This affected one (Patient #3) of ten patient records reviewed. This had the potential to affect all patients. The facility census was 179.

Findings include:

Record review revealed Patient #3 presented to the emergency department from an assisted living facility on 10/04/21 at 12:29 P.M. with altered mental status, increased lethargy, and an increased white blood cell count (WBC) with possible pneumonia. The decision was made to admit the patient.

On 10/04/21, the patient was transferred from the Emergency Department to 5 Tower. A staff nurse completed a fall risk assessment using the Morse Fall Scale (a method of assessing a patient's likelihood of falling) on admission, as required by facility policy. The patient received a score of 85 which placed her in the high risk for fall category.

Review of the fall interventions listed in the Daily Cares/Safety flow sheet on 10/05/21, 10/06/21 and 10/07/21 through 6:30 P.M. revealed, among basic and moderate elements, the patient's bed was in a low position, and a video camera and bed alarm were in place as interventions to prevent the patient from falling.

A nursing note dated 10/07/21 at 8:05 P.M. documented fall precautions were in place. The bed was locked and in the lowest position, four of four side rails were raised, non-slip socks on, call light and over bed table within reach.

A nursing note dated 10/07/21 at 9:43 P.M. documented "This RN out checking telemonitors and noticed patient was not in bed. Patient was found on the floor. Bed alarm was not on. Camera was in patient room. This RN rushed into patient's room. Patient was responsive, denies hitting head. Patient able to state first name, disoriented to time, place, and situation (baseline, history dementia). Large skin tear noticed on patient's left arm."..."Patient transferred to bed using Hoyer lift. Skin tear cleansed and dressing applied. Vital signs taken, stable. Patient had bowel movement. Patient changed and peri care given. New Purewick placed on patient. New IV placed and IV fluids started. Patient can move all extremities." The patient's primary care physician was notified of patient's fall and asked to order CT scan and X-ray of the right elbow and right hip. The patient's family was also notified of the fall.

Review of the Daily Cares/Safety flow sheet after the patient's fall revealed the bed alarm was on the patient's bed post fall, on 10/07/21 at 11:32 PM, as required by facility policy.

On 10/08/21, X-ray results revealed the patient had sustained a fracture of the right hip. The patient underwent surgery to repair the hip on 10/09/21. Post surgery, the patient was transferred to 4 Tower.

During interview on 01/03/22 at 10:47 A.M., Staff A confirmed all four side rails were up and the patient attempted to climb over the side rails and fell to the floor. Patient #3 was oriented to only person and would not have been able to lower the side rails without assistance. The side rails were a restraint and there was no physician order for restraints of any kind for Patient #3.

Review of the facility policy titled "Use of Restraints for Nonviolent, Non-Self Destructive Patient Situations", approved 11/02/21, documented restraints may be used in response to limit mobility or, temporarily immobilize a patient related to a medical condition. Any use of restraints is based on the assessed needs of the patient by a physician, licensed independent provider or registered nurse and assures that the patient and his or her rights, dignity, and well-being are preserved. A patient's physical and emotional needs are considered while the individual is in restraints. The basic rights of human dignity and respect are maintained, and physical well being is preserved through adequate exercise, nourishment, and personal care. Assessment is required every 2 hours (by the RN or LPN under supervision of the RN) to include:

* Visual/safety check
* Circulation/Skin Integrity
* Range of motion
* Fluids
* Food and Meal
* Elimination

Under the subheading of "Devices that Serve Multiple Purposes", the policy instructs staff that four side rails in the "up" position are considered a restraint.

Based on record review, interview and policy review, the facility failed to ensure patients who were restrained were assessed every two hours. This affected three (Patients #7, #8, and #11) of ten patient records reviewed. The facility census was 179.

Findings include:

1. Record review revealed Patient #7 presented to the Emergency Department (ED) on 12/17/21 at 6:11 P.M. with complaints of severe abdominal pain, nausea, and vomiting since the night before. The ED physician progress note stated the patient's spouse had been diagnosed with COVID-19. The decision was made to admit the patient with diagnoses including altered mental status, and cholecystitis (inflammation of the gallbladder).

The patient was admitted to 5 Tower on 12/18/21 at 12:43 A.M. Patient #7 continued to pull lines and interfere with medical treatment. On 12/19/21 at 2:55 A.M. a physician order was obtained for bilateral wrist restraints. Restraints were initiated at 4:10 A.M. There was no documentation Patient #7's restraints were assessed on 12/20/21 from 12:00 AM to 7:15 AM.

During interview on 01/04/22 at 12:15 P.M., Staff B confirmed there was no assessments documented.

2. Record review revealed Patient #8 was transported by Emergency Medical Services (EMS) to the ED on 11/23/21 at 3:36 P.M. with complaints of shortness of breath that started that day. The patient's oxygen saturation was low at 83 percent on room air during triage in the ED. The decision was made to admit the patient with a diagnosis of acute respiratory failure with hypoxia.

The patient was admitted to 5 Tower on 11/23/21 at 8:19 P.M. A nursing note dated 11/24/21 documented the patient was medicated with Hydralazine at 6:49 A.M. to lower his/her blood pressure. The note stated that the patient reported "feeling weird." The "patient was freaking out trying to get out of bed, rude to other nurses, pulling off oxygen." The patient was placed in bilateral soft wrist restraints. A physician order for restraints was obtained on 11/24/21 at 8:08 A.M.

Review of the restraint monitoring flow sheet revealed an assessment on 11/25/21 at 12:00 A.M. Patient #8 was asleep. There was no further restraint assessment documented again until the restraints were discontinued a 6:34 A.M.

During interview on 01/04/22 at 02:45 P.M., Staff A confirmed there was no assessments documented.

3. Record review revealed Patient #11 was transported from a rehab facility by EMS with altered mental status and a rapid heart rate on 12/27/21 at 1:32 P.M.. An emergency physician noted the patient was normally verbal at baseline but at that time the patient was nonverbal. The patient was admitted for care.

The patient was admitted to 5 Tower. On 12/27/21 at 8:32 P.M. a physician order was obtained for bilateral soft wrist restraints to prevent the patient from interfering with medical equipment and pulling lines.

Review of the restraint monitoring flow sheet documented on 12/28/21 at 6:00 A.M., Patient #11 was sleeping. There was no further restraint assessment documented again until the restraints were discontinued at 4:04 PM.

On 01/04/22 at 3:10 P.M., Staff B confirmed there were no assessments documented.

Review of the facility policy titled "Use of Restraints for Nonviolent, Non-Self Destructive Patient Situations", approved 11/02/21, documented restraints may be used in response to limit mobility or, temporarily immobilize a patient related to a medical condition. Any use of restraints is based on the assessed needs of the patient by a physician, licensed independent provider or registered nurse and assures that the patient and his or her rights, dignity, and well-being are preserved. A patient's physical and emotional needs are considered while the individual is in restraints. The basic rights of human dignity and respect are maintained, and physical well being is preserved through adequate exercise, nourishment, and personal care. Assessment is required every 2 hours (by the RN or LPN under supervision of the RN) to include:

* Visual/safety check
* Circulation/Skin Integrity
* Range of motion
* Fluids
* Food and Meal
* Elimination

Based on record review, interview and policy review, the facility failed to ensure staff activated bed alarms for patients assessed at high risk for falls. This affected two (Patients #4 and #7) of ten medical records reviewed. This had the potential to affect any patient assessed for high fall risk at the facility. The facility census was 179.

Findings include:


1. Record review revealed Patient #4 revealed the patient was transported to the Emergency Department by Emergency Medical Services (EMS) on 11/14/21 at 7:44 AM with complaints of abdominal pain, shortness of breath, intractable nausea, vomiting, and diarrhea. An emergency physician's progress note stated the patient was recently discharged from the facility on 11/09/21 after admission for similar complaints. The patient complained of being "weaker and weaker" and had fallen a couple of weeks prior. The patient was admitted for treatment.

The patient was admitted to 5 Tower, a step down unit for COVID-19 and other medical surgical patients, on 11/14/21 at 6:40 P.M. A staff nurse completed a fall risk assessment using the Morse Fall Scale (a method of assessing a patient's likelihood of falling) on admission, as required by facility policy. The patient received a score of 85 which placed him/her in a high risk for fall category.

On 11/14/21 at 10:00 P.M., the Daily Cares/Safety flow sheet documented fall risk interventions in place which included an alarm on the patient's bed. On 11/18/21 at 6:14 A.M., the alarm remained on the bed. There was no further documentation of fall risk interventions until 8:48 P.M.

On 11/19/21 at 6:13 AM, the flow sheet documented the alarm was on the patient's bed. There was no further documentation of fall risk interventions until 8:27 P.M.

On 11/20/21 at 06:10 AM the flow sheet documented the alarm was on the patient's bed. There was no further documentation of fall risk interventions until 8:02 PM.

A brief synopsis of the patient's hospital stay revealed the patient fell on 11/20/21. Although the synopsis revealed the provider was aware, the medical record lacked documentation of a progress note describing the fall.

Review of the facility's incident report, dated 11/20/21, documented the patient's nurse walked into the patient's room to find him/her on the floor with the walker in front of him/her. The patient reported falling while attempting to get up to the bathroom. The bed alarm was not set. Two nurses assisted the patient back in bed where the patient denied any pain and denied hitting his/her head.

The medical record lacked documentation staff placed an alarm on the patient's bed or performed any fall risk interventions from 11/21/21 at 7:11 AM until 7:59 PM.

During interview on 12/29/21 at 4:35 P.M., Staff A stated it was discovered there was no alarm on the patient's bed to alert staff that the patient was out of the bed as required with a high risk fall patient. Staff A revealed that staff members must reset the bed alarm after every time the patient is out of bed. It was also confirmed that the medical record lacked documentation that staff nurses noted fall interventions in place to prevent a fall every two hours as required by facility policy. Staff A was asked for details of a root cause analysis. Staff A revealed there was no root cause analysis performed as there was no injury and the physician was notified.

3. Record review revealed Patient #7 presented to the Emergency Department on 12/17/21 at 6:11 PM with complaints of severe abdominal pain, nausea, and vomiting since the night before. Patient #7 was admitted to the facility.

The patient was admitted to 5 Tower on 12/18/21 at 12:43 AM. A staff nurse completed a fall risk assessment using the Morse Fall Scale on admission. The patient received a score of 85 which placed him/her in a high risk for fall category.

There was no documentation the bed alarm was activated on 12/18/21 from 1:46 P.M. A nursing note at 11:47 P.M. stated the patient was very anxious, agitated, and confused. The patient fell out of bed onto the floor and began "crying out" stating he/she had hit his/her head. The patient was medicated with Geodon (antipsychotic used to treat schizophrenia and bipolar disorder) intramuscularly and ultimately placed in bilateral soft wrist restraints.

During interview on 01/04/22 at 12:15 P.M., Staff B confirmed that the patient was a high risk for falls and the medical record lacked documentation the bed alarm was activated.

Review of the facility policy titled "Bon Secours Mercy Health Fall Prevention", approved and effective on 09/21/20, documented the purpose of the policy is to identify those patients who are at the greatest risk for falling, implement a plan of care to promote their safety, document the assessments and safety measures instituted, alert other care team providers to patient's potential for falling, and provide guidelines for management of a patient in the event of a fall.

Standard fall precautions, for all patients, include, but are not limited to the following interventions:

1. Orient the patient to the environment, especially the location of the bathroom.
2. Provide a safe environment by clearing a pathway free of plugs, IV poles, and other obstructing items.
3. Call light and frequently used items within patient reach.
4. Intentional rounding.
5. Bed in lowest position and wheels locked, as applicable to the type of bed, when a patient is resting in bed, raise bed to a comfortable height when the patient is transferring out of bed, as appropriate.
6. Assess need for use of bedside commode, urinal, or elevated toilet seat, intentional toileting
7. Reinforce activity limits and the use of handrails to patients and families.
8. Non-slip footwear and proper fitting clothes.
9. Supplemental lighting (i.e. bathroom light, night light, bed light, etc.)

Moderate fall risk interventions include (for Morse Fall Risk tools ONLY):

In addition to following the Universal Fall Precautions above, moderate risk fall patients should have the following:

1. Place fall risk armband on patient.
2. Update Patient Care Plan with fall risk.
3. Explain "Stay With Me" program upon admission, and reinforce each shift.
4. Post fall risk signage/visible indicator.

High fall risk interventions include:

High fall risk patient will have the following interventions in addition to the standard and moderate interventions:

1. Fall risk arm band or jewel (yellow) note
2. Fall risk indicator on door (except in ED)
3. High fall risk banner displayed in the electronic medical record (EMR).
4. Use bed/chair alarm
5. Consider additional interventions including:
*Moving patient to more visible area
*Fall mats
*Low beds
*Telesitter if indicated by nursing judgement. Physician order not necessary.

The Post Fall Management section of the policy instructs staff of the following tasks:

1. Patient Experiences a Fall

*Complete a post fall assessment including vital signs and neuro check
*Call a Rapid Response, if indicated
*Document description of the fall in the progress notes.
*Communicate any changes in the plan of care related to the fall.
*If patient authorizes, notify patient's family that patient has fallen.

2. The house provider/attending physician is contacted as soon as possible for patients experiencing a fall with any one of the following:

*Loss of consciousness
*Change in mental status following the fall
*Known or suspected blow to the head
*Injuries exceeding minor hematomas and lacerations (restrictions in mobility, joint range or motion
or change in weight bearing status)
*The patient is on an anticoagulant medication.