HospitalInspections.org

The facility failed to meet the regulatory requirements for the Condition of Participation: §482.13 Patient's Rights as evidenced by:

Based on interview and record review, the hospital failed to ensure one of four sampled patients (Patient 1) was provided safe care when:

1. Emergency Department (ED) staff did not communicate and implement high fall risk interventions when Patient 1 was placed in a room out of the line of site of the ED staff, and the patient was left unattended while attempting to use the bathroom (Refer to A-0144).

2. The ED staff did not communicate and implement Physical Therapy (PT) recommendations for the use of a front wheel walker (FWW - assistive device) and nursing assistance when out of bed (OOB). (Refer to A-0144)

3. Medical Surgical (MS - general care area of hospital) staff did not communicate and implement PT recommendations for the use of a FWW and nursing assistance when OOB. (Refer to A-0144)

4. MS staff did not communicate and implement high fall risk interventions when Patient 1 was left unattended while using the urinal (handheld container used to urinate at the bedside). (Refer to A-0144)

These failures resulted Patient 1 falling twice, suffering a brain injury, and an unexpected death.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure safe patient care, in compliance with Conditions of Participation for Patient's Rights.

Based on interview, and record review, the hospital failed to follow its policy and procedure (P&P) titled, "Patient Safety Observation," for one of four sampled patients (Patient 1) when:

1. There was no order for Patient 1's safety observation.

2. Patient 1's safety observation logs were incomplete.

These failures had the potential for decreased communication among Patient 1's health care team and placing the patient's safety at risk.

Findings:

1. During a concurrent interview and record review on 4/2/25 at 10:32 a.m. with Director of Licensing and Certification (DLC), Patient 1's "Orders," dated 2/22/25 through 2/24/25 were reviewed. The Orders indicated Patient 1 did not have a order for Remote Safety Observation (RSO - staff monitoring video remotely for patient safety). DLC stated there were no orders for Patient 1 to have RSO and there should have been an order.

During a concurrent interview and record review on 4/2/25 at 11:45 a.m. with Director of Acute Care (DAC), Patient 1's "Med Sitter (MS - list of patients on RSO)" document (undated) was reviewed. The MS indicated Patient 1 was on RSO starting 2/22/25 at 10:11 p.m. through 2/24/25 at 12:58 a.m. DAC stated Patient 1 was admitted to the medical surgical unit on 2/22/25 at approximately 10 p.m. DAC stated Patient 1 was identified as a high risk for falls and was started on RSO until he was transferred to the direct observation unit (DOU) on 2/24/25 at approximately 1 a.m.

2. During a concurrent interview and record review on 4/2/25 at 11:41 a.m. with Medical Surgical Patient Safety Observer (MSPSO) 2, Patient 1's "Remote Patient Safety Observer (PSO) Observation Log (ROL)," dated 2/22/25 through 2/23/25 was reviewed. There was no ROL for RSO for 2/23/25. MSPSO 2 stated she was responsible for RSO of Patient 1 during the day shift (7 a.m. to 7 p.m.) on 2/23/25. MSPSO 2 stated ROL documentation of the patient's activity and events should have been documented every hour. MSPSO 2 stated there was no ROL for 2/23/25 day shift.

During an interview on 4/2/25 at 1:45 p.m. with Medical Surgical Registered Nurse Supervisor (MSRNS), MSRNS stated when a patient is assessed as a high risk for falls the staff utilize RSO. MSRNS stated the registered nurses are able to place orders for the RSO. MSRNS stated the MSPSO is responsible for monitoring and documenting the behavior and status of the patient every hour on the ROL.

During a concurrent interview and record review on 4/3/25 at 8:12 a.m. with MSPSO 1, Patient 1's "ROL," dated 2/22/25 through 2/23/25 was reviewed. There was no ROL for RSO on 2/23/25. MSPSO 1 stated she was responsible for RSO of Patient 1 during the night shift (7 p.m. to 7 a.m.) on 2/23/25. MSPSO 1 stated the staff should document every hour on the ROL. MSPSO 1 stated there was no ROL for 2/23/24 on the night shift.

During a review of the hospital's P&P titled, "Patient Safety Observation," dated July 2023, the P&P indicated, "It is the policy of [hospital name] that the assignment of patient safety observers is determined by nursing staff on a case-by-case basis, considering established inclusion and exclusion criteria and individual patient needs. The level and type of observation (in-person or remote) will be determined based on the patient's specific needs and level of risk. All decisions regarding patient observation will be made in the best interest of the patient's safety and with the goal of preventing harm to the patient and others. . . 4. Patient behavior, activity and safety will be documented hourly and upon change in behavior on Associated Form, #3807, Remote Bedside Patient Safety Observer Observation Log. . . E. Requirements for all Remote and In-Person Observations 1. Observation Orders a) Nursing orders for a specific type of observation will be entered into the medical record and reviewed and renewed daily, as indicated."

Based on interview and record review, the hospital failed to ensure one of four sampled patients (Patient 1) was provided safe care when:

1. The Emergency Department (ED) staff did not communicate and implement high fall risk interventions when Patient 1 was placed in a room out of the line of site of the ED staff, and the patient left unattended while attempting to use the bathroom.

2. The ED staff did not communicate and implement Physical Therapy (PT) recommendations for the use of a front wheel walker (FWW - assistive device) and nursing assistance when out of bed (OOB).

3. Medical Surgical (MS - general care area of hospital) staff did not communicate and implement PT recommendations for the use of a FWW and nursing assistance when OOB.

4. MS staff did not communicate and implement high fall risk interventions when Patient 1 was left unattended while using the urinal (handheld container used to urinate in at the bedside).

These failures resulted Patient 1 falling twice, suffering a traumatic brain injury, and an unexpected death.

Findings:

1. During a review of Patient 1's "History and Physical Reports (H&P)," dated 2/22/25 at 1:10 p.m., the H&P indicated Patient 1 was brought to the ED after hitting his head during a ground level fall at home. The H&P indicated Patient 1 was having weakness, used a walker at home, and required assistance with activities of daily living (ADLs - basic self-care activities like bathing, dressing, and eating).

During a concurrent interview and record review on 4/2/25 at 8:07 a.m. with ED Registered Nurse (EDRN) 3, Patient 1's "Patient Experienced a Fall (PEF)," dated 2/22/25 at 7:40 p.m. was reviewed. The PEF indicated Patient 1 had an unwitnessed fall in his ED room on 2/22/25 at 7:35 p.m. EDRN 3 stated she was assigned to care for Patient 1 in the ED for the 2/22/25 night shift (7 p.m. to 7 a.m.). EDRN 3 stated Patient 1 was not in his room when she received report from the day shift (7 a.m. to 7 p.m.) EDRN 2. EDRN 3 stated she was in another patient's room when ED Patient Care Technician (EDPCT) informed her that Patient 1 was on the ground in his room. EDRN 3 stated Patient 1 was assessed as a high risk for falls and needed to be in the line of site of the nurse's station for observation. EDRN 3 stated it was common that patients assessed as a high risk for falls were assigned a one-to-one observer (1:1 - one staff is assigned to monitor one patient), but Patient 1 did not have a 1:1 observer.

During a concurrent interview and record review on 4/2/25 at 9:24 a.m. with EDRN 1, Patient 1's "ED Triage (EDT)," dated 2/22/25 at 10:31 a.m. was reviewed. The EDT indicated Patient 1's Morse Fall Risk Score was 50 (assessment used to determine risk of falls, 0-24 low risk, 25-45 moderate risk, 45 or above high risk). The EDT indicated, "ED Additional Fall Risk Interventions: Do not leave patient unattended while toileting." EDRN 1 stated Patient 1 was assessed as a high risk for falls, was placed in an ED room, but was not in the line of site of staff for observation. EDRN 1 stated patients assessed as high risk for falls usually have a 1:1 observer, but Patient 1 did not have a 1:1 observer.

During an interview on 4/2/25 at 10:45 a.m. with EDRN 2, EDRN 2 stated he was assigned to care for Patient 1 in the ED for the 2/22/25 day shift. EDRN 2 stated if a patient has a history of falls and during the assessment the nurse scores the patient a high risk for falls, then he would work with the charge nurse to move the patient closer to the nurses station for observation. EDRN 2 stated he did not recall if that was done for Patient 1 on 2/22/25.

During a concurrent interview and record review on 4/3/25 at 10:43 a.m. with EDRN 4, Patient 1's "EDT," dated 2/22/25 at 10:31 a.m. was reviewed. The EDT indicated Patient 1 was assessed as a high risk for falls and staff were not to leave Patient 1 unattended while toileting. EDRN 4 stated the triage nurse should have communicated with EDRN 2 that Patient 1 was a high risk for falls and should not be left unattended while toileting. EDRN 4 stated Patient 1 needed to be placed in a room that could be seen from the nurses station for observation.

During an interview on 4/3/25 at 1:33 p.m. with Director of Emergency Department (DED), the DED stated the expectation was if a nurse assessed a patient to be a high risk for falls, the patient should be moved to a room in the line of site of the nurses station for observation.

2. During an interview on 4/2/25 at 10:45 a.m. with EDRN 2, EDRN 2 stated he did not recall receiving report from PT on 2/22/25 for recommendations to use the FWW with nursing when OOB.

During a concurrent interview and record review on 4/2/25 at 11:32 a.m. with Director of Rehabilitation Services (DRS), Patient 1's "PT (physical therapy) Inpatient Evaluation (PTE)," dated 2/22/25 at 3 p.m. (completed in the ED) was reviewed. The PTE indicated, "Mobility Level Score 4 [unsteady, walk assisted (minimal assist)]. . . Pt [Patient 1] is recommended to use a FWW [front wheeled walker] for any OOB [out of bed] activity at this point. Pt is safe to be OOB w/ [with] nursing, but will need assistance due to unsteadiness." DRS stated according to the evaluation Patient 1 was not safe to be up independently. DRS stated the recommendations for Patient 1's use of FWW and OOB with nursing would be communicated to the EDRN assigned to Patient 1's care. DRS stated walkers were available in the ED for patient use. DRS stated it was best practice to document who the recommendations were reported to, but there was no documentation that PT gave report.

3. During a concurrent interview and record review on 4/2/25 at 1:45 p.m. with Medical Surgical Registered Nurse Supervisor (MSRNS), Patient 1's "PTE," dated 2/22/25 was reviewed. The PTE indicated Patient 1 had a mobility level score of four. MSRNS stated a mobility level score of four meant the patient needed assistance when out of bed and during ambulation. MSRNS stated the staff should report the use of assistive devices (FWW) and other special interventions needed to incoming staff.

During an interview on 4/3/25 at 8:50 a.m. with Medical Surgical Patient Care Technician (MSPCT) 1, MSPCT 1 stated she was assigned to care for Patient 1 when he was transferred from the ED to the MS unit on 2/22/25 at approximately 10 p.m. MSPCT 1 stated MSRN 2 reported that Patient 1 was a high risk for falls, but MSRN 2 did not indicate the patient required a FWW and nurse assistance when OOB. MSPCT 1 stated she did not ask Patient 1 if he used a walker and did not provide him one.

4. During a concurrent interview and record review on 4/2/25 at 1:59 p.m. with MSRNS, Patient 1's "Morse Fall Risk Score" dated 2/23/25 at 7:25 p.m. was reviewed. The Morse Fall Risk Score for Patient 1 was 85 (patients who score 45 or above are considered a high for falls). MSRNS stated Patient 1 was a very high risk for falls. MSRNS stated she spoke to MSPCT 1 after Patient 1's fall, and MSPCT 1 stated if she had known Patient 1 required a walker then maybe he would not have fallen. When MSRNS was asked if it was best practice for staff to leave Patient 1's side while standing and using a urinal, MSRNS provided no response.

During an interview on 4/3/25 at 8:12 a.m. with MS Patient Safety Observer (MSPSO) 1, MSPSO 1 stated she was assigned to remote observation (video screen used to monitor patient safety from a separate location) for Patient 1 on 2/23/24. MSPSO 1 stated Patient 1 needed to use the restroom and tried to get out of bed. MSPSO 1 stated she pressed the alarm so staff would respond to Patient 1 immediately. MSPSO 1 stated she observed MSPCT 1 enter Patient 1's room and assist him to stand at the side of the bed. MSPCT 1 handed Patient 1 a urinal then left his side to go around to the other side of the bed and fix the linens. MSPSO 1 stated it appeared that Patient 1 went to sit on the side of his bed, missed the bed and fell to the floor. MSPSO 1 stated Patient 1 was a high risk for falls and MSPCT 1 should not have left his side while he was up OOB using the urinal.

During a concurrent interview and record review on 4/3/25 at 8:34 a.m. with Medical Doctor (MD) 1, Patient 1's "Progress Notes (PN)," dated 2/23/25 at 10:34 a.m. was reviewed. The PN indicated, "Patient [1] states that he is doing fine this morning. Denies any concerns at this time. Patient reports that he has been eating and sleeping well. Patient states that his weakness has improved. . . Imaging CT [computed tomography - a type of x-ray] Brain/Head w/o [with out] Contrast [medication used to enhance the x-ray] 2/22/25 12:10 [p.m.] . . . Impression . . . 3. No acute intracranial hemorrhage." MD 1 stated Patient 1 "did not look like he was in bad shape when came to ED." MD 1 stated Patient 1's Glasgow Coma Scale (GCS - assess level of consciousness, 3-8 severe head injury, 9-12 moderate head injury, 13-15 mild head injury) was 15 when he arrived to the ED. The medical team was anticipating to discharge Patient 1 home or to a rehabilitation care facility.

During an interview on 4/3/25 at 8:50 a.m. with MSPCT 1, MSPCT 1 stated she was with Patient 1 when he fell on 2/23/25 at approximately 8:25 p.m. MSPCT 1 stated she entered Patient 1's room and observed him trying to sit on the side of the bed. MSPCT 1 stated she put the bed rail down and assisted Patient 1 to sit on the side of the bed, but he wanted to stand up to use the urinal. MSPCT 1 stated once Patient 1 was standing, she handed him the urinal, left his side, and went around to the other side of the bed to straighten the bed linen. MSPCT 1 stated Patient 1 started to step back and she told him "one moment" in Spanish (Patient 1 was Spanish speaking), as she started to go around the bed to assist him, he fell to the floor on his left side and hit his head on the wall. MSPCT 1 stated when Patient 1 hit his head he started making a "snoring" sound. MSPCT 1 stated Patient 1 had a laceration and swelling on the left side of his face just below his eye. MSPCT 1 stated she was assigned to care for Patient 1 the night before (2/22/25) and knew that he was a high fall risk. MSPCT 1 stated Patient 1 was not using a FWW at the time of the fall. The FWW was hanging on the wall behind the door (in his room).

During a concurrent interview and record review on 4/3/25 at 10:30 a.m. with MD 2, Patient 1's "Discharge Documentation (DD)," dated 2/25/25 at 12:20 p.m. was reviewed. The DD indicated Patient 1 had a fall with head injury while admitted to MS unit (on 2/23/25). The DD indicated Patient 1 was moved to the Direct Observation Unit (DOU - unit providing a step-down level of care between intensive care unit and MS unit) and the initial exam indicated a GCS score of 11 (a score of 9-12 indicates a moderate head injury). The DD indicated staff took Patient 1 for a CT where he began vomiting. Upon return to the DOU Patient 1's GCS was a 6 (a score of 3-8 indicates a severe head injury) and the staff intubated (tube placed in airway to assist with breathing) the patient to protect the airway. The DD indicated Patient 1 was pronounced dead on 2/24/25 at 7:17 p.m. MD 2 stated the fall with the head injury, while admitted to the hospital, likely caused Patient 1's death.

During a concurrent interview and record review on 4/3/25 at 10:32 a.m. with MD 2, Patient 1's "Computed Tomography (CT)," dated 2/22/25 at 12:10 p.m. was reviewed. MD 2 stated there was no evidence of bleeding in Patient 1's brain after the fall at home and prior to the falls in the hospital.

During a concurrent interview and record review on 4/3/25 at 10:33 a.m. with MD 2, Patient 1's "CT," dated 2/23/25 at 9:22 p.m. was reviewed. MD 2 stated the CT was done after Patient 1's fall with head injury (2/23/25 at 8:25 p.m.) while admitted on MS unit. MD 2 stated the CT showed subdural hemorrhages (bleeding in the brain).

During a concurrent interview and record review on 4/3/25 at 10:34 a.m. with MD 2, Patient 1's "CT," dated 2/24/25 at 5 a.m. was reviewed. MD 2 stated the CT showed Patient 1 had significantly worsening bleeding in his brain.

During a concurrent interview and record review on 4/3/25 at 10:37 a.m. with MD 2, Patient 1's "Certificate of Death (CD)," dated 2/27/25 was reviewed. The CD indicated, "Cause of Death (A) Traumatic Brain Injury [TBI - caused by external force] (B) Ground Level Fall (C) Ischemic Strokes [blood clots in the brain]." MD 2 stated Patient 1's fall with the TBI, while admitted to the hospital, caused Patient 1's death.

During a review of the hospital's P&P titled, "Fall Risk Assessment and Prevention," dated April 2024, the P&P indicated, "To provide a consistent process for nursing assessment of patient fall risk and implementation of an individualized fall prevention plan. . . A. Assessment and Interventions . . . 2. Admitted patients 14 years of age or older. . . 3) Fall prevention interventions (see Addendum B) will be implemented according to the calculated risk. . . (c) High Risk - Implement high-risk fall prevention interventions. . . 4) The following fall prevention standards will be integrated into nursing practice: . . . (b) Patient fall risk and special prevention strategies will be communicated during hand-off. . . (d) Patients will be mobilized early, per Up Sooner, Safer standardized procedures. . . (g) Environmental safety will be continually monitored and supported throughout care. . . 6. Emergency Department (ED) a) Fall Risk Assessment . . . (c) Staff will complete a safety plan and implement the necessary precautions. . . Addendum B . . . Fall Prevention Interventions - Nurse will include in IPOC or Assess Patient's Need: High Risk. . . Shift Report Communicate patient's fall risk status during bedside report. Review history of falls and special prevention strategies. Plan of Care Collaborate with multi-disciplinary team members in planning individualized care, i.e. pharmacy, PT, OT. . . Safety. . . Do not leave patient unattended while toileting. . . Consider placing patient in room near nursing station for closer observation during first 24-48 hours of admission. Consider use of staff observer for patient safety."

During a review of the hospital's P&P titled, "Progressive Mobility Program: Up Sooner, Safer," dated August 2024, the P&P indicated, "To set forth [Hospital's name] standards for assessment and mobilization of patients, which promotes return to maximum functional capacity and supports requirements for safe patient handing [sic] by caregivers. . . B. RN Responsibilities for Admitted Acute Care Patients. . . c) Assess patient mobility level each day shift, upon change in level of care and change in patient condition, per the Mobility Assessment Algorithm (refer to Addendum B). . . 2. Communicate mobility level and planned activities within care team and to patient/support person(s) via: . . . SBAR [Situation/Background/Assessment, Recommendation communicate tool to provide information] /verbal report. . . c) Integrate planned mobility activities into the care schedule utilizing appropriate safe patient handling equipment according to assessed mobility level, per Up Sooner, Safer: Progressive Mobility/Safe Patient Handling Guide (refer to Addendum C). . . C. PT [Physical therapy] and OT [Occupational therapy] Responsibilities. . . 2. Intervention a) Provide recommendations and establish PT/OT treatment plan in addition to Up Sooner, Safer progressive mobility program. . . 3. Other Responsibilities. . . b) Collaborate regarding patient discharge needs with health care team. . . Addendum C Up Sooner, Safer: Progressive Mobility/Safe Patient Handling Guide. . . 4 - Walk Assisted (Minimal Assist). . . Durable Medical Equip [equipment]: - Cane/Crutches/Walker."

During a review of the hospital's P&P titled, "Patient Safety Observation," dated July 2023, the P&P indicated, "It is the policy of [hospital name] that the assignment of patient safety observers is determined by nursing staff on a case-by-case basis, considering established inclusion and exclusion criteria and individual patient needs. The level and type of observation (in-person or remote) will be determined based on the patient's specific needs and level of risk. All decisions regarding patient observation will be made in the best interest of the patient's safety and with the goal of preventing harm to the patient and others. . . A. Registered Nurse (RN) Responsibilities 1. Patient Assessment a) Nursing assessments/screens will be used to determine the most appropriate interventions and, as necessary, the use of a remote or in-person patient observer to support the safety needs of the patient in accordance with [hospital name] policies and standards. . . (b) Utilization of patient safety equipment/assistive devices. . . 2) Alternative Interventions (a) Relocation or placement of the patient closer to the nurse's station for observation or change in patient room for reduction of stimulation. . . (b) Engagement of family or support persons for additional patient companionship during hospitalization, as appropriate. (1) Family and support persons are not qualified observers but may agree to provide companionship. Nursing will meet with the volunteer(s) develop a plan for participation and provision of information on safety and staff communication. 3. Communication with Health Care Team a) Communicates with the provider regarding patient safety and the medical plan of care, e.g. necessity of IV lines, urinary catheters, central lines, sequential compression devices and medication management. b) Collaborates with physical therapy and dietary, as appropriate. . . 2. Remote Bedside Observation versus In-Person Observation . . . a) All patients who qualify for observation must first be trialed with remote observation monitoring before in-person observation is approved, unless the patient, in need of observation, meets the following exclusion criteria: . . . 4) Emergency Department (ED) patient (remote bedside observation not used in the ED). . . 2) Fall risk patients with a condition that increases risk of injury, if a fall were to occur. . . (c) Coagulation disorders."

During a review of the hospital's P&P titled, "Patient Rights and Responsibilities," dated April 2022, the P&P indicated, "2. Patients have a right to: . . . Receive care in a safe setting."