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Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure at-risk patients were protected from falls, and appropriately care for patients post-fall, when one discharged patient (#1) of one discharged patient reviewed, fell, suffered a fractured hip, and did not receive ongoing assessments or medical care related to her injury for approximately eight hours. (A-0395)
- Appropriately investigate and recognize failures related to a fall with injury for one discharged patient (#1) of one discharged patient reviewed, to mitigate the risk of falls and the potential for unidentified injuries for other at risk patients. (A-0395)
- Ensure staff performed adequate fall risk assessments and implemented measures to prevent patient falls per hospital policy for 10 current patients (#3, #7, #8, #9, #10, #12, #14, #19, #40 and #41) of 20 current patients reviewed that were at a high risk for falling. (A-0395)
- Ensure patient vital signs were checked and documented per physician order prior to administration of antihypertensive medications for three patients (#5, #6 and #7) of three patient charts reviewed. (A-0395)
- Follow hospital policy and verify patient identification prior to administration of medication for eight patients (#7, #11, #15, #18, #19, #40, #41 and #47) of eight patients observed without a patient identification armband. (A-0405)

These practices resulted in a systemic failure and noncompliance with 42 CFR 482.23 Condition of Participation: Nursing Services. The hospital census was 93.

Based on observation, interview, record review and policy review, the hospital failed to:
- Ensure at-risk patients were protected from falls, and that staff appropriately cared for patients post-fall, when one discharged patient (#1) of one discharged patient reviewed fell, suffered a fractured hip, and did not receive ongoing assessments or medical care related to her injury for approximately eight hours.
- Appropriately investigate and recognize failures related to a fall with injury for one discharged patient (#1) of one discharged patient reviewed, to mitigate the risk of falls and the potential for unidentified injuries for other at risk patients.
- Ensure staff performed adequate fall risk assessments and implemented measures to prevent patient falls per hospital policy for 10 current patients (#3, #7, #8, #9, #10, #12, # 14, #19, #40 and #41) of 20 current patients reviewed that were at a high risk for falling.
- Ensure patient vital signs were checked and documented per physician order prior to administration of antihypertensive medications for three patients (#5, #6 and #7) of three patient records reviewed.

The lack of consistent patient assessments, use of interventions, and investigation after a fall, placed all fall risk patients and patients on antihypertensive medications at risk for serious harm or injury. The hospital census was 93.

Findings included:

1. Review of the hospital's policy titled, "Fall Assessment and Precautions," dated 10/23/19, showed:
- All inpatients shall be assessed for potential risk for falls during the admission process, each shift and as needed when clinical status warrants.
- Inpatients at risk for falls shall be placed on fall precautions.
- The assigned nurse shall identify patients on fall precautions by placing an orange armband on the patient's wrist and an orange "fall precautions" sign adjacent to the patient's door.
- Assessment after a fall would include not moving the patient until asking the patient what he/she thinks caused the fall and assess associated symptoms, determine whether serious injury had occurred, conduct a head to toe assessment to include neurologic, cardiac, musculoskeletal, and skin assessment.
- The assigned nurse shall notify the on call psychiatrist, the medical physician to schedule further medical evaluation and treatment, the patient's personal representative, and the patient's family.
- The assigned nurse will obtain orders for additional monitoring and reassessment as directed by the physician.
- The assigned nurse shall initiate, or evaluate and update the patients "fall risk problem plan."

Review of the hospital's policy titled, "Precautionary Levels at CenterPointe Hospital," dated 09/09/21, showed that an appropriate order level of precautions was to be documented on the admission orders and patient observation record, and that patients on fall precautions are observed every 15 minutes and as needed. Staff will make every effort to provide a safe environment for patients, and provide walking assistive devices as indicated.

Review of the hospital's policy titled, "Sentinel Event Reviewing and Reporting," revised 09/30/21, showed the following:
- A reviewable sentinel event applies to events that include a patient fall that results in a fracture.
- A serious incident, which potentially meets the sentinel event definition, must be reported to the Administrator-On-Call, Chief Executive Officer (CEO), Chief Medical Officer (CMO), and Director of Risk Management or their designee.
- Responsibility of overseeing a Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) and implementation of any indicated improvement activities lies with the Director of Risk Management, President of the Governing Board or their designee, CEO and CMO.
- Upon completion of the RCA, a report will be provided to the CEO, CMO, Medical Executive Committee and Senior Management Team for their review and opportunity for additional input regarding the improvement actions recommended.

2. Review of Patient #1's medical record showed the following:
- She was an 87 year old female admitted on 07/14/22 for major depression, recurrent with psychosis (a serious mental illness characterized by defective or lost contact with reality) and dementia with behavioral issues. Physician documentation on admission showed that Patient #1 was confused and preoccupied.
- Nursing documentation upon admission, showed that the patient had an unsteady gait and walked with a walker, which put her at increased risk for falls and made her a high fall risk. There were no documented interventions upon her admission.
- Nursing documentation showed that fall precaution interventions were to be in place because Patient #1 did not have a normal gait and used a walker or wheelchair for ambulation and was often confused.
- Staff II, LPN, documented on 08/10/22 at 11:05 PM, showed that Patient #1 was found lying on the floor during 15 minute patient safety rounds. The patient stated that she fell, but the cause of the fall was not documented. Patient #1 needed assistance by two people to get into bed. She complained of pain in her right hip area. Attempts to contact two physicians were unsuccessful, so a voicemail message was left. There was no documentation in the medical record that family was contacted.
- Staff II, LPN, documentaion showed a post fall assessment completed at 11:05 PM, indicated that Patient #1 was oriented to herself only. The patient complained of right hip pain, and her range of motion was limited due to the pain, however the patient's vital signs were assessed with the patient sitting and standing, after the fall.
- Nursing flowsheet indicated that Patient #1 was given Tylenol at 11:30 PM for pain, but there was no pain level documented. There was no assessment documented to follow up on the administration of Tylenol for Patient #1's pain. Patient #1 slept through the night, but when she awoke, she was unable to bear weight on her right leg. The record indicated that nursing assisted her to the bathroom, even though she was unable to bear weight on her right leg. The patient was evaluated, the supervisor and physician were contacted, and she was sent to an acute care hospital for evaluation on 08/11/22 at 6:40 AM.
- There was no nursing documentation indicating that a nurse had assessed, or seen Patient #1 between the fall on 08/10/22 at 11:30 PM and 08/11/22 at 6:40 AM.
- 15 minute rounding sheets completed by mental health technicians (MHTs) between 8:46 PM and 5:46 AM on 08/11/22, showed the patient was sleeping, lying down, or situation appropriate, and did not indicate that Patient #1 was found on the floor or that she experienced any pain.

Review of Patient #1's medical record obtained from Hospital B (acute care hospital), showed she presented to the emergency department (ED) via ambulance on 08/11/22 at 7:02 AM, with complaints of right hip pain after a fall. She was admitted to the hospital with a fracture of the right hip.

During an interview on 09/14/22 at 9:45 AM, Staff X, MHT, stated that she found Patient #1 on the floor, wrapped around the wheels of her roomates wide wheelchair, during the evening and night change of shift rounds with Staff KK, MHT. Patient #1 had tripped over her roommate's wheelchair which was placed between their beds, leaving little room to walk around it. Patient #1 often got up during the night to use the bathroom or just walk around, and the roommate's wheelchair should not have been placed where it was. After the fall, the patient stated, "my hip" and couldn't move her legs because she was in so much pain. Staff KK, MHT, and Staff FF, RN, had to put the patient in the bed because she couldn't put any weight on her leg, and Patient #1 kept hollering "my leg, my leg." Staff X stated that she told Staff FF, RN, that Patient #1's hip was broken.

During an interview on 09/14/22 at 3:30 PM, Staff II, Licensed Practical Nurse (LPN), stated that it took three staff members to get Patient #1 back into her bed after she fell. Patient #1 was very confused and complained of right leg pain. She told Staff FF, LPN, that Patient #1 would need an x-ray to rule out a broken bone, and assumed Staff FF would take care of it. Staff II stated that attempts to contact the physicians should have continued until they were able to speak with them, and not leave a voice message. She was very surprised that Patient #1 was not transferred out for an x-ray until the following morning.

During an interview on 09/14/22 at 1:00 PM, Staff FF, LPN, stated that when she began her shift on 08/10/22, she was informed that Patient #1 had fallen in her room and was complaining of hip pain. She called the physician, but was unable to reach him, and believed she left him a message on his voicemail, and felt that was all she needed to do. She was concerned about Patient #1, but didn't believe the patient's injury was serious, and did not assess or check on Patient #1 after her fall until the next morning. In the morning, Patient #1 needed assistance getting to the bathroom, and could not bear weight on her right leg. Staff FF again attempted to call the physician but was still unable to reach him. Staff FF verified that she did not notify Patient #1's family about the fall, but could not explain why.

During an interview on 09/15/22 at 9:00 AM, Staff KK, MHT, stated that he was doing rounds with Staff X, MHT, at shift change, when they found Patient #1 on the floor. They tried to stand the patient up, but she was not able to bear any weight. Patient #1 complained of severe right upper leg pain, and was only able to stand with assistance. He was concerned all night that Patient #1 had a broken hip, and felt an ambulance should have been called for immediately after her fall. Patient #1 continued to complain of leg pain throughout the night, which he reported to the nurse, Staff FF, RN. All of the staff could hear her moaning, so he was sure the nurse knew the patient was in pain. The next morning, Patient #1 was found to be "in shock," shaking and pale, and they called the ambulance.

During an interview on 09/13/22 at 8:36 AM, Staff P, RN Supervisor, stated that Patient #1 fell on 08/10/22, shortly after she began her shift. She was the House Supervisor that night, so she was in charge of all the units. Patient #1 did not appear to be injured after her fall, but could not bear weight on her right leg, so they put her in bed. Staff eventually spoke with the physician at 6:00 AM the following morning. Staff P stated that line of sight (LOS, continuous visual contact with the patient) or a one to one (1:1, continuous visual contact with close physical proximity) could be provided for high fall risk patients, but added that Patient #1 was not considered a high fall risk.

During an interview on 09/14/22 at 1:40 PM, Staff EE, Doctor of Medicine (MD), stated that he did have a record of a voice message being left on his phone on 08/10/22 at 11:30 PM, but was no longer able to retrieve the voice message (content of message was unknown), and he received another phone call from the hospital on 08/11/22 at 5:56 AM, which was when he ordered Patient #1 to be transferred to another hospital for a post-fall evaluation. He was on call for medical issues on the night of 08/10/22.

During an interview on 09/14/22 at 11:00 AM, Staff Z, MD, confirmed he did not speak with a nurse regarding Patient #1's fall until early in the morning on 08/11/22, when he was informed that the patient could not bear weight on her right leg.

3. Review of the hospital's report titled, "Medical Executive Committee," dated 08/12/22, showed that findings from the incident investigations/RCA related to Patient #1's fall, had been discussed with the CEO and CMO, and that no improvement actions were recommended.

During an interview on 09/13/22 at 3:45 PM, Staff A, Risk Management/Performance Improvement Director, stated that no staff interviews were completed after Patient #1's fall with injury, because they did not feel there was a need to interview staff.

During an interview on 09/14/22 at 4:15 PM, Staff D, Chief Nursing Executive (CNE), stated that she reviewed Patient #1's medical record, but did not remember if she was involved in the fall investigation, and didn't know why staff weren't interviewed during the investigation. Her expectation of staff was to complete fall risk assessments and implement fall precaution interventions every shift. Her expectation for staff, when dealing with patient falls, was to do the post fall assessment, notify the physician of the findings, and continue to call them every 30 minutes until they were able to contact them, which she felt was hospital policy. Staff D confirmed that there was no education done with staff following the incident.

Hospital staff failed to follow their Fall Assessment and Precautions Policy for the care of the patient after a fall. The physicians were unable to be reached immediately after the fall, and so no orders for treatment were received. The family was not notified. No orders were obtained for additional monitoring and reassessment of Patient #1, so she was not assessed or monitored by nursing staff throughout the night. The MHT did not document that the patient was moaning throughout the night, and while he stated in his interview that he did report it to the nurse, his documentation did not reflect this. The only way to determine how Patient #1's fell was through interview, as there was no documentation of what caused Patient #1's fall documented in the record. Per hospital policy during the assessment post fall, if the patient had not lost consciousness, staff were to ask the patient what caused their fall and assess associated symptoms. Patient #1 laid in bed and was reported to be moaning in pain, for over six hours with a broken hip. Since the investigation did not include any staff interviews, they relied on the medical record and incident report and didn't get an accurate account of the events. Additionally during the survey, several issues were identified that continued to place high fall risk patients at a greater risk for falls.

4. Review of Patient #3's medical record showed the following:
- She was a 49 year old female admitted to the hospital on 07/28/22 for Electro-convulsive Therapy (ECT, a psychiatric treatment in which seizures in the brain are electrically induced to provide relief from mental disorders [increases risk of falls]).
- Nursing completed an admission fall risk assessment on 07/28/22, and determined the patient was at risk for falls based on her history of falls, and indicated fall precautions should be initiated.
- Physician's orders dated 07/29/22, indicated that Patient #3 was to be placed on fall precautions.
- Physician documentation indicated the patient would begin ECT on 07/29/22 and continue every Monday, Wednesday and Friday.
- From 09/06/22 through 09/14/22, 25 nursing flowsheets were completed by nursing staff. 14 out of 25 nursing assessments failed to identify the patient as a fall risk, and inconsistently documented whether fall precautions were in place.

During an interview on 09/13/22 at 2:05 PM, Staff N, MHT, stated that ECT treatments placed a patient at an even greater risk for falls, and would need to be monitored closely after they returned from their treatment.

Observation with concurrent interview on 09/12/22 at 3:00 PM, on Unit 4, showed Patient #3 was not wearing an orange armband. Patient #3 stated she had never been given an orange armband to wear.

Observation on 09/14/22 at 11:00 AM, in the ECT room, showed Patient #3 was not wearing an orange armband.

Review of Patient #12's medical record showed the following:
- He was a 40 year old male admitted to the hospital on 09/08/22 for alcohol (ETOH) detoxification (detox, the process of removing drugs or alcohol from the body [increases risk of falls]).
- Nursing admission assessment completed on 09/09/22 showed the fall risk assessment as ETOH detox, which indicated fall precautions should have been initiated.
- Physician's orders and alcohol detox orders dated 09/09/22, indicated that Patient #12 was to be placed on fall precautions.
- From 09/09/22 through 09/13/22, 10 nursing flowsheets were completed by nursing staff. Two out of 10 nursing assessments failed to identify the patient as a fall risk, and inconsistently documented whether fall interventions were in place.

Observation with concurrent interview on 09/13/22 at 3:45 PM, on Unit 5, showed Patient #12 was not wearing an orange armband. The patient stated he had never been given an orange armband to wear.

Review of Patient #14's medical record showed the following:
- He was a 34 year old male admitted to the hospital on 09/07/22 for depression and suicidal ideations.
- On 09/14/22 at 12:15 PM, the patient received ECT.
- ECT order sets indicate that seizure and fall precautions were to be initiated.
- On 09/14/22, three nursing flowsheets were completed by nursing staff. Only one assessment, at 6:00 AM, indicated he was wearing a fall band and that he was a fall risk due to having ECT.

Observation on 09/14/22 at 1:15 PM, on Unit 5, showed Patient #14 was standing in his room and did not have an orange armband on, and there was no orange fall precaution sign outside the patient's door.

Review of Patient #19's medical record showed the following:
- He was a 35 year old male admitted to the hospital on 09/07/22 for suicidal ideations, alcohol and drug dependence.
- The undated nursing admission assessment showed the fall risk assessment as ETOH detox, which indicated fall precautions should have been initiated.
- Physician's orders dated 09/07/22 indicated that Patient #19 was to be placed on fall precautions.
- From 09/07/22 through 09/13/22, 14 nursing flowsheets were completed by nursing staff. Seven out of 14 nursing assessments failed to identify the patient as a fall risk, and inconsistently documented whether fall precautions were in place.

Observation on 09/13/22 at 9:10 AM, on Unit 6, showed Patient #19 was standing in the hallway and was not wearing an orange armband.

Observation with concurrent interview on 09/13/22 at 4:05 PM, showed Patient #19 had on an orange armband. Patient #19 stated that the orange armband was just put on; he had not had one on since admission.

Review of Patient #9's medical record showed the following:
- He was a 71 year old male admitted on 09/02/22 for alcohol use disorder, with severe withdrawals (symptoms that occur when someone stops using alcohol after a period of heavy drinking).
- Nursing admission assessment completed on 09/02/22 showed that he was over 70 years old, had impaired vision, and alcohol detox, putting him at a high risk for falls.
- Physician's orders on 09/03/22 showed that Patient #9 was to be placed on fall precautions.
- Nursing documentation on 09/04/22 at 1:10 AM, showed that he was found in the floor by a MHT at 12:50 AM, next to his bed. Patient #9 stated that he got up to use the restroom and his legs got tangled and he fell. The physician was called at 1:40 AM and he instructed nursing staff to keep an eye on the patient for the rest of the night and he would see him the next morning. There was no documentation that Patient #9 was reassessed until 6:05 AM.
- Recent fall was not circled on the fall risk portion of the nursing flow sheets on 09/04/22 at 6:05 AM, 2:00 PM or 5:00 PM. The nursing flow sheet at 5:00 PM had no falls written under the diagnosis.
- Fall band was circled on the nursing flow sheet on the morning of 09/13/22 (indicating that he was wearing a fall band).

Observation on 09/13/22 at 9:30 AM, on Unit 7, showed Patient #9 stood up from his wheelchair without applying the brakes, then sat back down, again without applying the brakes (places the patient at risk of the wheelchair rolling away from when a patient stands up or sits down). He was not wearing an orange fall arm band.

During an interview on 09/13/22 at 2:22 PM, Staff V, LPN, stated that all the patients on Unit 7 were high fall risks. She did not know what the precautions for a patient who was a high fall risk were. If a patient was wearing an orange armband, she would "maybe" observe them more closely.

Review of Patient #10's medical record showed the following:
- He was a 37 year old male admitted on 09/11/22 for schizoaffective disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work, and may experience hearing voices that are not real).
- Nursing admission assessment documentation on 09/11/22 indicated that Patient #10 used a wheelchair for mobility, had a history of falls, a seizure disorder (sudden, uncontrolled electrical disturbance in the brain which cause changes in behavior, movements and/or in levels of consciousness [increases fall risk]), and impaired vision.
- Physician's orders dated 09/02/22 indicated that Patient #10 was to be placed on fall precautions, and was a high risk for falls.
- Nursing flow sheets on 09/13/22 at 6:00 AM and 10:23 AM, indicated that Patient #10 had on an fall band.

Observation on 09/13/22 at 9:39 AM, on Unit 7, showed Patient #10 in a wheelchair. He did not have an orange armband on.

During an interview on 09/13/22 at 2:05 PM, Staff N, MHT, stated that all patients on Unit 7 were considered high fall risks, and that none of the patients were managed differently based on their fall risk. Staff N added that Patient #10 should have been wearing an orange armband.

Review of Patient #7's medical record showed the following:
- She was a 71 year old female admitted on 09/05/22 for bipolar disorder (a mental disorder that causes unusual shift in mood by alternating periods of emotional highs and lows).
- Nursing admission assessment documentation dated 09/05/22 showed that Patient #7 used a walker and assistive devices for walking, and had an unsteady gait.
- The admission fall risk assessment did not indicate that Patient #7 was greater than 70 years of age and used a walker/wheelchair/cane, which would have placed her at a high risk for falls.
- Physician's orders dated 09/05/22, showed that Patient #7 was to be placed on fall precautions.
- An inpatient fall prevention notice was signed and dated on 09/06/22, indicating that Patient #7 had been given an orange fall band.
- From Patient #7's admission on 09/05/22 through 09/14/22, 25 nursing flow sheets were completed by nursing staff. 24 out of 25 nursing assessments failed to identify the patient as a fall risk, and inconsistently documented whether fall precautions were in place.

Observation and concurrent interview on 09/13/22 at 9:57 AM, on Unit 7, showed Patient #7 walking with a walker, without an orange armband on. Patient #7 stated that she was never given an orange armband.

Review of Patient #8's medical record showed the following:
- She was a 77 year old female admitted on 09/04/22 for a depressed mood.
- Physician documentation indicated that Patient #8 would begin ECT treatments as soon as she was cleared for it.
- Physician's orders upon admission indicated that Patient #8 was to be placed on fall precautions.
- From Patient #8's admission on 09/04/22 through 09/14/22, 26 nursing flow sheets were completed by nursing staff. 22 out of 26 nursing assessments failed to identify the patient as a fall risk, and inconsistently documented whether fall precautions were in place.

Observation on 09/13/22 at 9:45 AM, on Unit 7, showed Patient #8 did not have an orange fall sign on her door and was not wearing an orange armband.

Review of Patient #40's medical record showed the following:
- He was a 34 year old male admitted on 09/12/22, for treatment of alcohol dependence.
- Physician's orders dated 09/12/22 indicated that Patient #40 was to be placed on fall precautions.
- From Patient #40's admission on 09/12/22 through 09/14/22, five nursing assessment flowsheets were completed by nursing staff. Four out of five nursing assessments failed to identify the patient as a fall risk, and inconsistently documented whether fall precautions were in place.

Observation and concurrent interview on 09/14/22 at 1:45 PM, on Unit 1, showed Patient #40 walking in the hall, without an orange armband on. Patient #40 stated that he had never been given an orange armband. Observation of the patient's room doorframe showed no fall magnet present.

Review of Patient #41's medical record showed the following:
- He was a 19 year old male admitted on 09/13/22 for alcohol dependence.
- Physician unit admission orders dated 09/13/22, indicated that Patient #41 was to be placed on fall precautions.
- From Patient #41's admission on 09/13/22 through 09/14/22, two nursing assessment flowsheets were completed by nursing staff. Zero out of two nursing assessments failed to identify the patient as a fall risk, and inconsistently documented whether fall precautions were in place.

Observation and concurrent interview on 09/14/22 at 1:50 PM, on Unit 1, showed Patient #41 walking in the hall without an orange armband on. Patient #41 stated that he had never been given an orange armband. Observation of the patient's room doorframe showed no fall magnet present.

During an interview on 09/14/22 at 10:15 AM, Staff J, LPN, stated that alcohol detoxification patients were always considered a fall risk. Fall precautions and interventions should include placement of an orange armband on the patient, and a fall magnet placed on the patient's room doorframe.

#5. Review of the hospital's policy titled, "Medication Administration," dated 03/06/18, showed that the hospital shall establish procedures for safe and accurate administration of medications, to promote a beneficial therapeutic response to prescribed medications, and to reduce the rates and risk of adverse events related to medication administration. Before administering prepared medications to the patient, the licensed nurse assesses and monitors the patient's response to the medications, noting physiologic response (e.g., pulse, blood pressure [BP]) when indicated.

Review of Patient #5's medical record and medication administration record (MAR) showed the following:
- He was a 46 year old male with a medical history of high BP.
- On 09/07/22, unit admission orders indicated vital signs before administration of antihypertensives (medication to reduce high blood pressure); notify physician if BP less than 90/60 or greater than 140/90 and heart rate (HR) less than 60 or greater than 100.
- On 09/11/22, only one set of vital signs was documented at 4:34 PM.
- On 09/11/22, the MAR indicated the patient was to receive Inderal (a medication used to treat high BP, chest pain, uneven heart beat and tremors) 10 milligrams (mgs, a measure of dosage strength) by mouth twice daily at 9:30 AM and 9:30 PM. Lisinopril (a medication used to treat high BP) 10 mgs by mouth every day at 9:30 AM, and Minipress (a medication used to treat high BP) 2 mgs by mouth at 9:30 PM. All three of the medications had an order to hold for manual systolic BP less than 90 or manual HR less than 60.
- On 09/11/22, there was no BP or HR documented on the MAR by these medications to indicate the patient's BP or HR was checked prior to administration of the medicine.

Review of Patient #6's medical record and MAR showed the following:
- He was a 41 year old male with a past medical history of high BP.
- On 06/03/22, unit admission orders indicated vital signs before administration of anti-hypertensive; notify physician if BP less than 90/60 or greater than 140/90 and HR less than 60 or greater than 100.
- On 09/11/22, only one set of vital signs was documented at 4:08 PM.
- On 09/11/22, the MAR indicated the patient was to receive Inderal 10 mgs. by mouth three times daily at 9:30 AM, 1:30 PM and 5:30 PM. The medication had an order to hold the medication for manual systolic BP less than 90 or manual HR less than 60.
- On 09/11/22, there was no BP or HR documented on the MAR by the 9:30 AM or 1:30 PM medication time to indicate the patient's BP or HR was checked prior to administration of the medicine. The 5:30 PM medication was administered at 5:44 PM without a documented HR to indicate it was reviewed prior to administration.

Review of Patient #7's medical record and MAR showed the following:
- She was a 71 year old female admitted on 09/05/22 for bipolar disorder and had a past medical history of high BP.
- On 09/05/22, unit admission orders indicated vital signs before administration of anti-hypertensive; hold for manual systolic BP of less than 90 or manual HR of less than 60.
-On 09/13/22, at 10:03 AM, only the HR was documented, and at 9:30 PM there was no documentation of a HR or BP to indicate the patients BP or HR was checked prior to the administration of the medication.
- On 09/11/22 at 8:45 PM, there was no BP or HR documented on the MAR by the medication to indicate the patient's BP or HR was checked prior to administration of the medication.
- On 09/08/22 at 9:30 AM, there was no BP or HR documented on the MAR by the medication to indicate the patient's BP or HR was checked prior to administration of the medication.
- On 09/07/22 at 9:30 AM and 9:30 PM, there was no BP or HR documented on the MAR by the medication to indicate the patient's BP or HR was checked prior to administration of the medication.

During an interview on 09/14/22 at 10:15 AM, Staff Y, LPN, stated that if a medication was required to be held if the patient's BP or HR was below a certain number, the policy was to document the BP and HR on the MAR.

During an interview on 09/14/22 at 1:40 PM, Staff GG, RN, stated that she documented the patient's BP and HR on the MAR if a medication indicated that a BP and HR was required prior to administering the medication.

During an interview on 09/14/22 at 1:40 PM, Staff EE, MD, stated that he would expect staff to follow the physician's order and check the patients BP and HR prior to medication administration.

During an interview on 09/14/22 at 4:30 PM, Staff D, CNE, stated that her expectation of staff was to document the patient's BP and HR on the MAR and the vital sign sheet prior to administering a medication that required a BP and HR to be obtained. Staff could use a BP or HR that had been taken on the patient within an hour or less.




41474

Based on observation, interview, record review and policy review, the hospital failed to follow hospital policy and verify patient identification (ID) prior to administration of medication for eight patients (#7, #11, #15, #18, #19, #40, #41 and #47) of eight patients observed without a patient ID wristband. This had the potential to cause harm to all patients without ID wristbands to be given the wrong medications without accurate patient verification. The hospital census was 93.

Findings included:

1. Review of the hospital's policy titled, "Medication Administration," dated 03/06/18, showed that the hospital shall establish procedures for safe and accurate administration of medications to promote a beneficial therapeutic response to prescribed medications and to reduce the rates and risk of adverse events related to medication administration. Before administering prepared medications to the patient, the licensed nurse verifies that the medication is to be administered to the RIGHT PATIENT by reviewing the wristband/ID picture, name and date of birth with the patient.

2. Observation with concurrent interview on 09/14/22 at 1:45 PM, on Unit 1, showed Patient #40 had no ID wristband. Patient #40 stated he had never had a wristband on since he was admitted on 09/12/22.

Review of Patient #40's Medication Administration Record (MAR) dated 09/13/22, showed no ID picture of the patient and he received six medications by mouth at 8:36 AM.

Review of Patient #40's medical record showed that physician's unit admission orders dated 09/12/22 indicated six daily scheduled medications were ordered and 10 PRN (as needed) medications. From Patient #40's admission on 09/12/22 through 09/14/22, five nursing flowsheets were completed by nursing staff, and none of the flowsheets indicated he had on an ID bracelet.

Observation with concurrent interview on 09/14/22 at 1:50 PM, on Unit 1, showed Patient #41 had no ID wristband. Patient #41 stated he had never had a wristband.

Review of Patient #41's MAR dated 09/14/22, showed no ID picture of the patient and he received five medications by mouth at 8:50 AM.

Review of Patient #41's medical record showed that physician's unit admission orders dated 09/12/22 indicated five daily scheduled medications were ordered and 10 PRN medications. From Patient #41's admission on 09/13/22 through 09/14/22, two nursing assessment flowsheets were completed by nursing staff, and none of the flowsheets indicated he had on an ID bracelet.

Observation with concurrent interview on 09/13/22 at 4:00 PM, on Unit 5, showed Patient #11 had no ID wristband. Patient #11 stated he had not had a patient identification wristband on for several days.

Review of Patient #11's MAR dated 09/13/22, showed no ID picture of the patient and he received eight medications by mouth at 9:15 AM.

Review of nursing documentation for Patient #11, showed that from 09/06/22 through 09/13/22, seven out of 18 nursing flowsheets indicated the patient had no ID bracelet.

Observation on 09/13/22 at 9:30 AM, on Unit 6, showed Staff S, Registered Nurse (RN), administered four pills to Patient #15 who was not wearing a patient ID wristband. Review of Patient #15's MAR showed no ID picture of the patient.

Observation on 09/13/22 at 9:35 AM, on Unit 5, showed Patient #47 was not wearing a patient ID wristband.

Review of Patient #47's MAR dated 09/13/22, showed no ID picture of the patient and he received two medications by mouth at 9:30 AM.

Observation on 09/13/22 at 9:45 AM, on Unit 6, showed Staff Q, RN, administered eight pills to Patient #18 who was not wearing a patient ID wristband. Review of Patient #18's MAR showed no ID picture of the patient.

Observation with concurrent interview on 09/13/22 at 4:15 PM, On Unit 6, showed Patient #19 was not wearing an ID wristband. Patient #19 stated he had not had a patient identification wristband on for several days.

Review of Patient #19's MAR dated 09/13/22, showed no ID picture of the patient and he received six medications by mouth at 9:40 AM.

Review of nursing documentation for Patient #19, showed that from 09/07/22 through 09/13/22, eight out of 14 nursing flowsheets indicated the patient had no ID bracelet.

Observation with concurrent interview on 09/13/22 at 9:57 AM, on Unit 7, showed Patient #7 was not wearing an ID wristband. Patient #7 stated that she had not had a patient ID wristband on since she got there.

Review of Patient #7's MAR dated 09/13/22, showed no ID picture of the patient and she received six medications by mouth, one inhalation medication, and one topical pain relieving medication at 10:05 AM.

Review of nursing documentation for Patient #7, showed that from 09/05/22 through 09/14/22, 13 out of 23 nursing flowsheets indicated the patient had no ID bracelet.

During an interview on 09/14/22 at 9:15 AM, Staff H, Mental Health Technician (MHT), stated that staff need the patients to wear their ID bands so that they know who they were. They previously had a picture of the patient in the medical record for identification until approximately one month ago.

During an interview on 09/13/22 at 10:00 AM, Staff S, RN, stated that staff were supposed to check the patient's wristband and stated name and date of birth before administering medications. If they didn't have a wristband, she just used the patient's stated name and date of birth. She was previously able to identify patients by a picture on their MAR, but they no longer had pictures of the patients on the MAR.

During an interview on 09/14/22 at 10:15 AM, Staff Y, Licensed Practical Nurse (LPN), stated that prior to medication administration, the right patient was verified by looking at the patient's wristband and asking the patient his or her name and date of birth. It was very important for patients to have an ID wristband, because over the past month, staff could no longer look at a photo to verify who the patients were. Staff Y added that new wristbands could be obtained from the Assessment and Referral Unit, if needed.

During an interview on 09/14/22 at 1:40 PM, Staff GG, RN, stated that prior to medication administration, she looked at the patient's armband and asked the patient his or her name and date of birth.

During an interview on 09/14/22 at 4:30 PM, Staff D, Chief Nursing Executive, stated that her expectation of staff was to verify the patient's ID by looking at the patient's armband and asking the patient's name and date of birth prior to medication administration.






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