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Based on interview and record review, the hospital failed to ensure the safety of 1 of 3 patients reviewed, Patient #2, as evidenced by failing to provide a physician ordered one to one sitter when Patient #2 was identified as being restless and at risk for a fall.

The findings included:

Patient #2 was admitted to the hospital on 10/29/18 with diagnoses to include left sided weakness and diabetes.

Review of a Nursing Note dated 10/30/18 at 5:00 AM, documents 'Patient continues being anxious and very restless wanting out of bed.'

Review of a Physician Order dated 10/30/18 at 7:04 AM documents a one to one sitter on a constant basis.

Review of the clinical record revealed Patient #2 was transferred from a critical care unit to the neurological telemetry unit on 10/30/18 at 7:30 PM. Nursing documentation on 10/31/18 at 12:01 AM documents a one to one sitter is at Patient #2's bedside.

Review of the Constant Observer Flow Sheet dated 10/31/18 revealed the last one to one sitter observation documentation ends on 10/31/18 at 6:45 AM.

Further review of Nursing Note documentation dated 10/31/18 at 7:08 AM, states 'No sitter at bedside at this time per order; Charge nurse and supervisor notified. Oncoming nurse notified.'

Review of a Nursing Note dated 10/31/18 at 7:30 AM documents 'Patient found on floor by charge nurse (no injury). Night supervisor notified on sitter order from 10/31/18. Night shift supervisor informed nurse that she does not have any sitters for the patient.'

Review of a Nursing Note dated 10/31/18 at 11:20 AM documents, 'Patient attempted to get out of bed. Assigned nurse contacted supervisor and told him that patient needs sitter for safety. Supervisor informed nurse "we do not have any sitters and there is nothing that I can do." Charge nurse informed on conversation with supervisor.'

Further review of the clinical record revealed from 10/31/18 at 7:08 AM to 11/02/18 at 8:32 PM when the patient was discharged, no documentation of a one to one sitter at the patient's bedside and no order to discontinue the one to one sitter.

On 11/21/18 2:35 PM, an interview was conducted with the Risk Manager who stated a one to one constant observation order has to be discontinued by a physician. She was unable to speak to why Patient #2 was not provided with a one to one sitter as ordered.

On 11/21/18 at 2:45 PM an interview was conducted with the Director of Neuroscience Division who was unable to explain the reason why no sitter was available for Patient #2. She stated possibly the family was at the bedside. She was apprised that 22 minutes after the RN documented the patient had no sitter at the bedside, the patient was found on the floor. She had no further comment.

Review of the hospital policy for Constant Observer Assessment, Implementation and Discontinuation states in part, 'The Hospital recognizes that Constant Observers may be utilized in order to provide continuous observation of a patient to support safety... If an assessment reveals that a patient is a danger to self and/or others a constant observer will be implemented immediately. A constant observer at the bedside takes priority.... Constant observer is ordered by a physician. Appropriate chain of command may always be implemented to meet the patient's needs.'

Based on interview and record review the hospital failed to ensure Interdisciplinary Care Plans were initiated and updated to reflect the status of 3 of 3 patients reviewed, Patient #1, Patient #2 and Patient #3, as evidenced by failing to initiate a care plan for safety interventions after an incident with injury was sustained by Patient #1; failing to address additional safety measures initiated for Patient #2; and failing to initiate a care plan to reflect an injury sustained by Patient #3 post a fall.

The findings included:

Review of the hospital policy for Interdisciplinary Care Summary and Education Record states in part, 'The Interdisciplinary Care Summary and Education Record will be used to document, by number and measurable goal, the plan of care and education plan... The Interdisciplinary Care Summary and Education Record is updated daily, and when there is a change in patient's condition, based on the nursing assessment.'

1) Patient #1 was admitted to the hospital on 10/11/18 with diagnoses to include end stage renal disease, diabetes and altered mental status.

Review of a Nursing Note dated 10/14/18 at 5:38 PM, the Registered Nurse documents 'Patient found at edge of bed between walker and bed. Assisted back to chair. Patient complained of left leg weakness. Stated that foot got caught in bedrail while getting out of bed.' Further review of the clinical record revealed Patient #1 sustained a fracture of the left foot as a result of this incident and required surgical intervention on 10/18/18.

Review of the Interdisciplinary Care Plans for Patient #1 revealed between 10/12/18 through 10/17/18, no review, revision or initiation of any care plans related to the incident and the outcome of the incident. Further review of the Interdisciplinary Care Plans revealed care plans initiated on 10/18/18 post operatively for 'Impaired Mobility related to operative procedure', and 'Safety Concerns related to high risk for falls.' Review of the Event Report note dated 10/19/18 completed by the Risk Manager documented the 'Patient resisted and refused to allow the nurse to remove the sock and shoe on the left foot telling the nurse that those were her diabetic shoes and needed to have them on.' Further review of the Care Plans revealed no documentation of an assessment of a potential safety hazard of wearing shoes in bed and a potential for entrapment of the patient's foot between the mattress and side rail with her shoes on.

2) Patient #2 was admitted to the hospital on 10/29/18 with diagnoses to include left sided weakness and diabetes.

Review of the Interdisciplinary Care Plans initiated on 10/29/18 by nursing identifies the patient as having 'Altered neurological status related to disease process and stroke.'

Review of a Nursing Note dated 10/30/18 at 5:00 AM documents the 'patient continues being anxious and very restless wanting out of bed, redirected.' Further review of the clinical record revealed a physician order obtained for a one to one sitter at the patient's bedside to maintain close observation of the patient.

Review of the Interdisciplinary Care Plans reveals no update or revision of the patient's care plans by nursing to address his anxious and restless state and new order for a one to one sitter to maintain safety as documented by nursing on 10/30/18 at 5:00 AM.

Review of a Nursing Note dated 10/31/18 at 7:30 AM documents 'Patient found on floor by charge nurse.' (No injury sustained.)

Review of the Interdisciplinary Care Plans reveals on 10/31/18 a care plan was initiated by nursing to now include 'Safety concerns related to high risk for falls' after the patient sustained a fall.

3) Patient #3 was admitted to the hospital on 10/24/18 with diagnoses to include dizziness, left sided weakness and diabetes.

Review of the Interdisciplinary Care Plans initiated on 10/24/18 by nursing identifies the patient as having 'Safety concerns related to high risk for fall' and 'Impaired mobility related to muscular weakness.'

Review of the clinical record nursing documentation dated 10/26/18 at 7:35 AM, revealed he was noted to be on the bathroom floor and sustained a laceration of the chin and a broken tooth.

Further review of the Interdisciplinary Care Plans revealed on 10/26/18 a Physical Therapist updated the 'Impaired mobility' care plan. Review of the 'Safety' care plan was not reviewed or updated by nursing post the fall incident. Additionally, there was no nursing care plan documentation regarding the now altered skin integrity related to the laceration of the chin the patient sustained with the fall.

On 11/21/18 at 12:25 PM, an interview was conducted with a Registered Nurse (RN) on the neurological telemetry unit where Patients #1 #2 and #3 resided during their hospital stay. An inquiry was made regarding patient care plans to which the RN demonstrated how they review the care plans every 12 hours and make changes or modifications as necessary depending on the patient's status.

On 11/21/18 at 3:00 PM, an interview was conducted with the Director of Neuroscience Division who after review of the care plans for Patient #1, Patient #2 and Patient #3 concurred they did not reflect the status of the patients before or after their respective incidents.