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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES, was out of compliance.

A-395: A registered nurse must supervise and evaluate the nursing care for each patient. Based on interviews and document review, the facility failed to ensure nursing care was provided and met the continuous care needs of patients. Specifically, nursing staff failed to implement preventive measures in order to prevent falls once high fall risk patients were identified in three of three medical records reviewed of high fall risk patients. (Patient #1, Patient #2, Patient #3)

Based on interviews and document review, the facility failed to ensure nursing care was provided and met the continuous care needs of patients. Specifically, nursing staff failed to implement preventive measures in order to prevent falls once high fall risk patients were identified in three of three medical records reviewed of high fall risk patients. (Patient #1, Patient #2, Patient #3)

Findings include:

Facility policy:

The Fall Prevention and Management Program policy read, all patients admitted to the inpatient setting will be assessed for fall "risk" using the Modified Morse Fall Risk on admission, each shift, change in status of the patient, and prior to patient discharge.

Identification of patient's assessed as high risk fall: Use for those who score High Risk on the Fall Risk Assessment (>45 on Modified Morse Fall Risk Assessment). A yellow wristband placed on patient to identify the patient to caregivers that patient had been assessed as a High Fall Risk. Place a fall alert symbol near the patient's door. Consider the use of safety technology for fall prevention: bed and chair alarm, seat belt alarm, low bed with defined perimeter mattress, non-skid floor mat, alarms at exits and nurse call and communication systems near patient reach.

Assessment of the patient post fall: done by nursing staff - assess patient for level of injury, assess airway, breathing and circulation (ABC), obtain vital signs and neuro checks when appropriate, assess for range of motion, alert physician, assess and treat any injury, assess and treat for pain and consider safety devices to prevent further falls e.g. bed/chair alarms seat belt alarms. Documentation and Communication: document circumstances in the medical record, notify family of fall, complete incident report and notify supervisor.
Reference:

The Fall Huddle/Debriefing Form read, steps to complete after a patient fall: call an overhead fall huddle, Registered Nurse (RN) and/or Medical Doctor (MD) to perform a post-fall patient assessment, primary nurse to document a post-fall assessment in the Electronic Medical Record (EMR), including vital signs, primary nurse to document a Nurse's Note using the significant event template, primary nurse or nursing supervisor to update the care plan with new interventions added based on the new Morse Fall Scale (MFS) score, primary nurse or nursing supervisor to complete an incident report

Include the following in your nursing note and incident report: date and time of fall and vital signs including blood glucose. Document whether the fall was witnessed or was the fall assisted. Names of witnesses and/or first responders and their observations. Did the patient sustain any injury? Document MD notification and family notification. Include Morse Fall Scale (MFS) Score prior to fall with date and time of MFS assessment.

1. The facility failed to ensure nursing staff implemented measures for the prevention of falls with high fall risk patients.

A. Patient #1, Patient #2 and Patient #3's medical records were reviewed and revealed a lack of evidence that fall preventative measures were in place at all times.

i. Patient #1 was admitted on 3/2/22 with a diagnosis of acute respiratory failure post cervical fusion surgery. Upon admission, Patient #1 had a MFS above 45 and was identified as a high fall risk patient. Subsequently, the patient sustained four falls at the facility.

a. Patient #1's medical record revealed from 3/2/22 to 4/4/22 nurse's patient care notes lacked evidence of fall prevention measures in place by nursing staff. For example:

Patient #1's medical record revealed in the hourly rounding logs, which included patient safety activity measures, there was no evidence of fall prevention measures initiated on the day shift for the following dates: 4/6/22, 4/8/22, 4/9/22, 4/13/22, 4/24/22, 5/7/22 and 5/10/22.

Patient #1's medical record revealed no evidence of a bed and/or chair alarm utilized on the day shift for the following dates: 4/10/22, 4/20/22, 4/29/22, 5/18/22 and 5/21/22.

There was no evidence of a bed and/or chair alarm utilized on the night shift for the following dates: 4/8/22, 4/13/22, 4/26/22, 4/30/22, 5/1/22, 5/4/22, 5/6/22, 5/12/22, 5/13/22, 5/20/22 and 5/24/22.

There was no evidence of a bed and/or chair alarm utilized for both day and night shift, a total of 24 hours, for the following dates: 4/7/22, 4/25/22, 4/27/22, 4/28/22, 5/2/22, 5/3/22, 5/8/22 and 5/19/22.

b. Patient safety events for Patient #1 regarding falls were entered on 4/6/22, 4/11/22, 4/23/22 and 5/3/22. Patient #1's medical record revealed no evidence of a post-fall assessment completed by either an RN or MD on 4/11/22, 4/23/22 and 5/3/22.

A patient safety event for Patient #1 regarding a fall on 4/6/22 at 4:10 p.m. was reviewed in conjunction with Patient #1's medical record. The review revealed there was no evidence of fall prevention measures initiated during the day shift on 4/6/22 when Patient #1 fell.

A patient safety event for Patient #1 regarding a fall on 5/3/22 at 12:00 p.m. was reviewed in conjunction with Patient #1's medical record. The review revealed there was no evidence of a bed and/or chair alarm utilized on the day shift of 5/3/22 when Patient #1 fell.

ii. Patient #2 was admitted on 3/24/22 with a diagnosis of acute respiratory failure and encephalopathy (broad term for any brain disease that alters brain function). Upon admission, Patient #2 had a MFS above 45 and was identified as a high risk fall patient. Subsequently, the patient sustained five falls at the facility.

a. Patient #2's medical record revealed from 3/4/22 to 4/20/22 nurse's patient care notes lacked evidence that fall prevention measures were in place by nursing staff. For example:

Patient #2's medical record revealed in the hourly rounding logs, which included patient safety activity measures, there was no evidence of fall prevention measures initiated on the day shift for the following dates: 4/24/22, 4/27/22, 5/8/22, 5/9/22, 5/10/22, 5/20/22 and 5/24/22.

There was no evidence of fall prevention measures implemented on the night shift for the following dates: 4/28/22, 5/5/22 and 5/11/22.

Patient #2's medical record revealed no evidence of a bed and/or chair alarm utilized on the day shift for the following dates: 4/23/22, 4/29/22 and 5/12/22.

There was no evidence of a bed and/or chair alarm utilized on the night shift for the following dates: 4/26/22, 4/30/22, 5/1/22, 5/6/22, 5/8/22, 5/9/22, 5/10/22, 5/14/22 and 5/15/22.

There was no evidence of a bed and/or chair alarm utilized for both day and night shift, a total of 24 hours, for the following dates: 4/25/22, 5/13/22 and 5/16/22.

b. Patient safety events for Patient #2 regarding falls were entered on 4/21/22, 4/27/22, 5/5/22, 5/9/22 and 5/16/22. Patient #2's medical record revealed no evidence of a post-fall assessment completed by either RN or MD on 4/27/22 and 5/16/22.

A patient safety event for Patient #2 regarding a fall on 4/27/22 at 3:35 p.m. was reviewed in conjunction with Patient #2's medical record. The review revealed there was no evidence of fall prevention measures initiated during the morning shift of 4/27/22 when Patient #2 fell.

A patient safety event for Patient #2 regarding a fall on 5/9/22 at 9:23 a.m. was reviewed in conjunction with Patient #2's medical record. The review revealed no evidence of fall prevention measures initiated during morning shift of 5/9/22 when Patient #2 fell.

A patient safety event for Patient #2 regarding a fall on 5/16/22 at 8:53 p.m. was reviewed in conjunction with Patient #2's medical record. The review revealed there was no evidence of a bed and/or chair alarm utilized on the day shift of 5/16/22 when Patient #2 fell.

iii. Patient #3 was admitted on 4/7/22 with a diagnosis of recurrent lower extremity cellulitis and bacteremia (bacteria in the blood system). Upon admission Patient #3 had a MFS above 45 and identified as a high risk fall patient.

a. Patient #3's medical record revealed no evidence of a bed and/or chair alarm utilized on the morning shift for the following dates: 4/8/22, 4/15/22 and 4/16/22.

There was no evidence of a bed and/or chair alarm utilized on the night shift for the following dates: 4/12/22 and 4/13/22.

There was no evidence of a bed and/or chair alarm utilized for both day and night shift, a total of 24 hours, for the following dates: 4/10/22, 4/12/22 and 4/17/22.

B. Interviews:

a. On 5/31/22 at 1:16 p.m., an interview with RN #1 was conducted. RN #1 stated a high fall risk patient was a patient with presentation of weakness, inability to walk on their own, and disorientation. An MFS was an assessment tool expected to be done every shift as MFS scores could change from day to day. RN #1 stated high fall risk patients were supposed to have fall prevention measures implemented which included lowering the bed to the lowest position, locking the bed, activating bed alarms, conducting hourly rounding and providing frequent toileting.

b. On 5/31/22 at 2:55 p.m., an interview with the director of nursing (DON) #2 was conducted. DON #2 stated a change in patient condition must be documented in the nurse's notes. She stated a patient fall was considered a change of condition. DON #2 stated staff were instructed to overhead page a Fall Huddle announcement so that a physician could assess the patient after a fall. However, DON #2 further stated the Fall Huddle/Debriefing Form was used as a guidance for staff but had not been consistently utilized or documented on.

DON #2 stated she was not aware there was an option to documented bed alarms in the rounding logs. She stated she expected nursing staff to document fall prevention measures in their nursing notes. Upon review of the medical records, DON #2 was unable to provide evidence of fall prevention measures being conducted at all times and all post-fall assessments completed post fall in Patient #1, #2 and #3's medical records.

c. On 6/1/22 at 9:46 a.m., an interview with MD #3 was conducted. MD #3 defined a fall as when someone unintentionally hit the floor and that it could be an assisted or unassisted fall. MD #3 stated patients must be assessed daily to determine if the patient was at risk for falls. MD #3 explained certain medical diagnoses may increase a patient's fall risk and medications may contribute to dizziness and confusion.

MD #3 stated during a Fall Huddle a provider was able to conduct a real time assessment of the event and patient. MD #3 stated a patient assessment and injury assessment was performed by a provider after a fall. MD #3 stated a debrief of the fall event with staff was expected to be done to determine the cause of patient fall; however, MD #3 stated debriefs were consistently not done. MD #3 stated he would usually document a physician's note of the fall event but this was not consistently done. MD #3 stated the expectation was for the primary staff to document a patient's change of condition and both the provider and nurse should document a post-fall assessment.