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Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure nursing staff implemented all appropriate fall prevention measures for 1 of 3 patients reviewed (Patient #1). Failure of nursing staff to implement all appropriate fall prevention measures resulted in Patient #1 falling from their bed and breaking their hip.

The cumulative effect of these systemic failures and deficient practices resulted in the CAH administrative staff's inability to ensure the nursing staff provided adequate nursing care to meet patient needs.

Please see C-1046.

Based on document review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure nursing staff implemented all appropriate fall prevention measures for 1 of 3 patients reviewed (Patient #1). Failure of nursing staff to to implement all appropriate fall prevention measures resulted in Patient #1 falling from their bed and breaking their hip. The CAH's administrative staff identified a census of 8 patients on entry.

Findings include:

1. Review of policy, "Fall Risk, Post Fall Assessment," last reviewed 4/25/22, revealed in part: Patients with a normal/low risk for falls will have routine interventions for safety and fall prevention. If a patient falls into a high risk category, standard interventions will be implemented as well as those for high risk patients. High risk fall interventions include:

1. If room available, move patient to room near nurse's station.
2. Do not leave patient unattended in the bathroom.
3. Frequent visual observation of the patient.
4. Use of various body, bed, or chair alarms.
5. One on one in person monitoring (1:1 sitter) if above interventions fail.

CAH failed to have a policy that specifically addressed 1:1 monitoring including identifying who would make the determination of the need for a 1:1 sitter, the frequency of provision of the 1:1 sitter service and how staff would document the provision of this service.

2. Review of policy, "Clinical Alarms," last revised 3/11/22, revealed in part: "Alarms on clinical monitoring and intervention systems will be maintained in the "on" position and will be sufficiently audible to staff. Alarms are not to be turned off. Alarms will be "on" as long as the equipment is being used for the patient."

3. Review of Patient #1's medical record revealed that on 9/25/23 at 1:47 PM, the CAH staff admitted Patient #1 for hospice respite (short-term relief for in-home hospice caregivers). Advanced Registered Nurse Practitioner (ARNP) A noted Patient #1 had pancreatic cancer and described the patient as thin and frail.

4. Review of contract between Hospice Provider A and CAH, effective 8/7/20, revealed:

a. CAH shall provide services to Hospice A patients to the same extent as other CAH
residents and make available to Hospice A patients "Patient Services" as may be authorized by the Hospice A Interdisciplinary Team.

b. "Patient Services" means those services provided by CAH consistent with the Plan of Care for a given Hospice Provider A patient. CAH shall provide to [Hospice Provider A] Patients patient services, including, but not limited to, treatment, medication, emergency services, nursing services, dietary, housekeeping, durable medical equipment and oxygen services customarily available at no additional charge to CAH residents. CAH shall provide twenty-four (24) hour nursing services that meet the nursing needs of all patients and are furnished in accordance with each patient's Plan of Care.

c. The CAH shall immediately notify Hospice Provider A of any significant change in a patient's physical, mental, social, emotional status occurs, or of any clinical complications that suggest a need to alter the plan of care.

d. Hospice Provider A was only responsible for furnishing and managing a patient's hospice care related to the terminal illness and related conditions; they were not responsible for managing all the patient's care. Hospice Provider A assumed and maintained the responsibility to provide services at the same level and to the same extent as those services would be provided if the patient were in their own home.

e. Hospice Provider A would ensure that mechanisms were in place to provide for coordination of all hospice
services provided to patients residing in CAH. Hospice Provider A would provide assistance as may be reasonable and necessary to CAH to satisfy its responsibilities to implement the provisions of this Agreement.

5. Review of Hospice Provider A's Team Care Plan provided by CAH, dated 9/21/23, revealed Mobility and Safety Interventions included the following:
a. Alarms to couch and bed due to poor memory, increased weakness, and use of walker.
b. Voice monitor (device that amplifies sound so could hear couch and bed alarms when not in the room) added to the home so that family caregiver was able to move about freely and not have to watch the patient at all times.

The hospice care plan did not include a requirement to have a 1:1 sitter prior to the patient's admission to the CAH, or at any time while the patient received hospice respite services at the CAH.

6. Review of Hospice Provider A's assessment dated 9/25/23 (same day as CAH admission) revealed Patient #1 was alert and oriented to person, place and situation. The patient was intermittently confused, cooperative and forgetful. Patient #1 often contradicted themselves within a few minutes of making a statement or answering a question. The patient would also state, "I don't know" or trail off mid-sentence and the patient's conversation was difficult to follow.

7. Further review of Patient #1's medical record revealed:

a. On 9/25/23 at 4:52 PM, RN B documented a fall risk score of 6 (low), and listed interventions as "bed/chair alarm".

b. On 9/25/23 at 5:44 PM, RN B documented that Patient #1 was forgetful and impulsive.

c. On 9/25/23 at 7:37 PM, CNA C confirmed additional fall interventions: "Armband/colored socks/signage; placement close to nurse's station".

d. On 9/25/23 at 8:27 PM, RN D documented Patient #1's bed alarm sounded when they attempted to get up independently.

e. On 9/26/23 at 12:39 AM, RN D identified Patient #1 had a fall risk score of 21 (high), noted Patient #1 was forgetful, impulsive, and had short term memory loss. The patient's medical record lacked documentation of CAH staff implementing any further safety interventions to prevent the patient from falling.

f. On 9/27/2023 at 12:48 AM, RN D documented that Patient #1 was alert and oriented to self and place with "loose orientation" to time. Patient #1 had been restless and impulsive the past few hours, their bed alarm had sounded multiple times when Patient #1 had attempted to get out of bed and ambulate to the bathroom independently. Patient #1 did not use their call light.

g. On 9/27/23 at 3:20 AM, RN D noted Patient #1 sounded the bed alarm again, and had not utilized their call light once during RN D's shift.

h. On 9/27/23 at 3:30 AM, RN D documented that the bed alarm had sounded and they were now monitoring the patient 1:1.

i. On 9/27/23 at 3:45 AM, RN D documented that they continued to monitor 1:1. RN D failed to document when they stopped monitoring Patient #1 1:1, or any further information regarding 1:1 sitter.

j. On 9/27/23 at 5:30 AM, RN D documented that Patient #1's bed alarm sounded after they attempted to get out of bed independently.

k. On 9/27/23 at 11:30 AM, CAH staff moved Patient #1 to another room that was even closer to the nurse's station.

l. On 9/27/23 at 4:25 PM, RN E documented that at 3:45 PM, CNA F heard Patient #1 hollering and found them sitting on the floor in their room. RN E did not note any internal or external of Patient #1's leg and Patient #1 denied pain in their legs or hips. Patient #1 was assisted from the floor, used the restroom, and then went back to bed. RN E notified the medical provider and placed a call to the hospice provider who agreed to have imaging done to determine if there was a fracture. RN E noted Patient #1 was forgetful, impulsive and had poor safety awareness and poor attention and concentration.

m. On 9/27/23 at 5:25 PM, x-ray results revealed Patient #1 had an age-indeterminate fracture of their right hip, recommend further imaging with Computed Tomography (CT) scan.

n. On 9/27/23 at 5:28 PM, RN E again noted Patient #1 was forgetful, impulsive, and had poor judgement. There was no change in Patient #1's care plan.

o. On 09/28/23 at 9:07 AM CT results revealed acute (recent) comminuted intertrochanteric fracture (right hip fracture).

p. On 9/28/23 at 10:32 AM (the morning after Patient #1 fell), SW G noted that Patient #1 had had a fall yesterday afternoon and they did have a right hip fracture. SW G wrote that per nursing staff, Patient #1 had been impulsive, did not use their call light, and was setting off their bed alarm. SW G was going to ask Hospice Provider A to provide a 1:1 sitter, and the CAH would provide a 1:1 sitter on 9/28/23 from 1:00 PM - 5:00 PM.

q. On 9/28/23 at 11:30 AM, CNA H noted that a Hospice Provider A CNA was now present to be a 1:1 sitter with Patient #1 (approximately 19 hours after Patient #1 sustained a fall that resulted in a hip fracture).

r. On 9/28/23 at 12:45 PM, Advanced Practice Registered Nurse (APRN) I noted that Patient #1 suffered a fall while getting out of bed unassisted, and x-ray of right hip showed possible hip fracture (CT confirmed). On exam, Patient #1 had a positive rotation of their right lower extremity (consistent with hip fracture). Patient #1's spouse was notified of the fall, had requested pain management as Patient #1 would not be a good candidate for surgical intervention. APRN I documented that they would ask the hospice provider to provide 1:1 sitters and the CAH staff would provide a sitter on 9/28/23 from 1:00 PM - 5:00 PM.

s. On 9/28/23 at 8:30 PM, RN K documented the patient had a 1:1 sitter at the bedside. RN K failed to document any further information regarding 1:1 sitter (such as when the sitter arrived, how long the sitter was present).

t. On 9/28/23 at 9:47 PM, RN J documented sitter at bedside RN J failed to document any further information regarding 1:1 sitter.

u. On 9/29/23, Nursing Services Director documented Hospice Provider A 1:1 sitter at bedside on each intentional rounding until 8:17 AM.

v. On 9/29/23 at 10:45 AM, the CAH staff discharged Patient #1 back home with Hospice Provider A per the hospice physician.

4. During an interview on 11/21/23 at 2:30 PM, ARNP A recalled admitting Patient #1 for hospice respite. Patient #1 was frail, and ambulated with a walker. Patient #1 had no evidence of any bone fractures on admission. ARNP A got a call from RN E after Patient #1 fell. Patient #1 did not initially complain of pain, but 30 minutes later they did have hip pain so ARNP A ordered a hip x-ray after Hospice Provider A approved.

ARNP A stated that CAH absolutely does use 1:1 sitters if they are not able to get patients to remain in bed. ARNP A did not think Patient #1 had a 1:1 sitter until after they fell and broke their hip.

5. During an interview on 11/21/23 at 3:00 PM, RN B recalled that they used their nursing judgement and added a bed and chair alarm to Patient #1's plan of care even though their fall risk assessment was "low". RN B did not know what their policy said re: 1:1 sitter, but did confirm that they would consider a 1:1 sitter if a patient was constantly setting off bed or chair alarms, had increased confusion, or was impulsive and would get up without assistance.

6. During an interview on 11/21/23 at 4:00 PM, RN C could not recall what their policy said regarding use of 1:1 sitter, but RN C did confirm that they did sit 1:1 with Patient #1 multiple times during the night before their fall. RN C stated they believed Patient #1 could benefit from a 1:1 sitter and it was a slower night so they had time to do it.

7. During an interview on 11/28/23 at 10:00 AM, RN E recalled Patient #1 was kind of "sassy", they knew what they wanted to do and would do it. RN E acknowledged that Patient #1 would get up out of bed without assistance when they wanted to which put them at risk for falls even with a bed alarm. RN E explained that Patient #1's bed alarm was going off so they went to their room and found them sitting on the side of the bed talking on their phone. RN E disengaged the bed alarm and sat down on the bed beside Patient #1. RN E then stepped out of the room to give Patient #1 some privacy during their phone call, and at some point after that they heard Patient #1 yelling and when RN E re-entered the room Patient #1 was sitting on the floor. RN E did an assessment, assisted Patient #1 to their feet, took them to the bathroom and then Patient #1 got back into bed. RN E did not note any injuries, cuts or bruises. Patient #1 denied pain at that time. RN E notified hospice provider to discuss next steps and the hospice provider approved an x-ray for the hip. Patient #'1 spouse declined any type of surgical intervention to repair the hip fracture.

RN E acknowledged they should not have left the room with the bed alarm disengaged when Patient #1 was sitting at the side of the bed. RN E could not recall what their policy was regarding use of a 1:1 sitter. When asked if they considered getting a sitter for Patient #1, RN E replied they couldn't say yes or no. RN E could not recall if Patient #1 had a 1:1 sitter after their fall, but thought it might not have been until the next day.

8. During an interview on 11/30/23 at 1:05 PM, CNA F recalled hearing Patient #1's voice or some kind of noise so they went to Patient #1's room and found them sitting on the floor. RN E then came in and started doing an assessment and asking Patient #1 if they were hurt or had any pain.

CNA F stated that Patient #1 did try to get out of bed frequently. CNA F did not recall if Patient #1 had a 1:1 sitter prior to their fall, and could not remember if anyone was assigned to be a 1:1 sitter after Patient #1 fell.

9. During an interview on 11/21/23 at 2:00 PM, APRN I recalled Patient #1 was frail and feisty, did what they wanted to do. APRN I confirmed the CT Scan of Patient #1's hip had shown an acute comminuted intertrochanteric fracture (hip fracture), and recalled that it was reported to them that the fall caused the fracture. APRN I examined Patient #1 after their fall and noted that Patient #1 had a positive rotation of their right lower extremity which is also indicative of a hip fracture. When asked if the CAH used 1:1 sitters, APRN I replied yes, sometimes, depending on the patient. APRN I did consider Patient #1 to be at risk, knew the patient had some confusion and the patient kind of did what they wanted to do. APRN I thought the hospice provided a sitter and that the CAH brought in a sitter overnight but could not recall dates or times.

10. During an interview on 11/21/23 at 3:30 PM, SW G explained that the morning after Patient #1 fell they had contacted the hospice provider to arrange for a sitter. SW G explained CAH staff determined Patient #1 needed a 1:1 sitter due to the patient still demonstrating impulsiveness and wanting to get up without using their call light. Patient #1's spouse was at their bedside during the stay, but they were encouraging them to go home and rest. SW G did not actually see the sitters, SW G documented the times they had been told that 1:1 sitters would be with Patient #1.

11. During an interview on 11/30/23 at 3:35 PM, RN K recalled that Patient #1 had a bed alarm, was not using their call light. They were concerned about Patient #1's safety. RN K recalled that during the night (unclear on which night or nights) Patient #1 had a 1:1 sitter from Hospice Provider A.

12. During an interview on 11/28/23 at 11:00 AM, RN J stated that if all fall risk interventions aren't effective then they should have a 1:1 sitter. RN J recalled that Patient #1 was in a room close to the nurses station, they did not have a sitter but family was there. RN J acknowledged that family would not function as a 1:1 sitter but they were an extra set of eyes and could have notified staff if a patient was getting out of bed.

13. During an interview on 11/28/23 at 2:00 PM, Chief Nursing Officer (CNO) explained that an RN should implement a 1:1 sitter if they don't feel they can keep the patient safe. CNO confirmed it would have been appropriate for Patient #1 to have had a 1:1 sitter prior to their fall.

14. During an interview on 11/28/23 at 11:30, RN Inpatient Service Manager confirmed that there were no immediate changes documented to Patient #1's care plan after Patient #1 had a fall with injury. The RN Inpatient Services Manager learned of the fall with injury the following morning, they did a post fall huddle, and at that time, decided to get a 1:1 sitter for Patient #1.

15. During an additional interview on 12/28/23 at 10:15 AM, the RN Inpatient Service Manger stated they tried to follow the hospice plan of care and continued to provide the same level of service as the patient had received at home. The RN Inpatient Service Manger explained that the hospice care plan was mostly used to assist the CAH in accepting or denying a referral. The RN Inpatient Service Manger CAH reported CAH staff do their best to align both the hospice and CAH care plans, but the hospice care plan was not accessible to direct care staff via their electronic medical record.

The RN Inpatient Service Manager was not aware that Patient #1's hospice care plan included a voice monitor. The RN Inpatient Service Manger explained that the CAH did not have a voice monitor, so this was not an intervention they could provide unless the hospice provider brought one to the CAH for use with the patient. The RN Inpatient Service Manger reported Hospice Provider A did not provide a voice monitor.

The RN Inpatient Service Manager did not think it was necessary to notify Hospice Provider A when RN D documented on 9/27/23 at 3:30 AM that CAH staff were now doing 1:1 monitoring of Patient #1. The RN Inpatient Service Manager explained that a hospice nurse came to the CAH every day to assess Patient #1, and CAH staff would have notified Hospice A when the hospice nurse came to assess the patient.

The RN Inpatient Service Manager stated that they felt Patient #1 needed a 1:1 sitter after they fell, and CAH staff did notify Hospice Provider A. The RN Inpatient Service Manger explained that during Patient #1's stay at the CAH, it would have been Hospice Provider A's responsibility to provide sitters. Initially the CAH provided the sitter and then they coordinated the sitter with Hospice Provider A.

16. During an interview on 11/30/23 at 1:45 PM, the Nursing Services Director confirmed that Patient #1 did not have a 1:1 sitter prior to their fall, and there was no immediate change in Patient #1's care plan after they fell on 9/27/23 at 3:45 PM and broke their hip. The first discussion of a 1:1 sitter was the next morning (9/28/23) at their morning Huddle. The Nursing Services Director also confirmed that CAH did not have a uniform way to document a 1:1 sitter in the medical record, and medical record lacked information regarding staff who provided 1:1 sitter, documentation of patient activity during the 1:1 sitter, and the exact times when a 1:1 sitter was present.

Based on medical record review, hospital policy review, hospice plan of care, hospice and hospital contract review and staff interview, the Critical Access Hospital (CAH) administrative staff failed to ensure there was appropriate and timely follow-up and intervention after 1 of 3 patients reviewed (Patient #1) sustained a fall with injury. Failure to ensure there was appropriate and timely follow-up and interventions after Patient #1 had a fall with injury potentially puts all patients at risk for a fall with injury which could result in additional patient injury or even death. The CAH's administrative staff identified a census of 8 patients on entry.

Findings include:

1. Review of policy, "Occurrence Reporting," last reviewed 4/26/22, revealed in part:

"Adverse Events are defined as unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, 'or at risk thereof' includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. These events are called 'adverse' because they signal the need for immediate investigation and response...[CAH] is responsible for changing care processes that may cause some of these events."

"In the case of any/all adverse events...these events need Immediate Investigation and response)..."

2. Review of contract between Hospice Provider A and CAH, effective 8/7/20, revealed:

a. CAH should provide services to Hospice A patients to the same extent as other CAH residents and make available to Hospice A patients "Patient Services" as may be authorized by the Hospice A Interdisciplinary Team.

b. "Patient Services" means those services provided by CAH consistent with the Plan of Care for a given Hospice Provider A patient. The CAH should provide to [Hospice Provider A] Patients patient services, including, but not limited to, treatment, medication, emergency services, nursing services, dietary, housekeeping, durable medical equipment and oxygen services customarily available at no additional charge to CAH residents. The CAH should provide twenty-four (24) hour nursing services that meet the nursing needs of all patients and were furnished in accordance with each patient's Plan of Care.

c. CAH should immediately notify Hospice A if there was a significant change in a patient's physical, mental, social, or emotional status occurs; or there were clinical complications that suggested a need to alter the plan of care.

d. Hospice A was only responsible for furnishing and managing a patient's hospice care related to the terminal illness and related conditions; they were not responsible for managing all the patient's care. Hospice A assumed and maintained the responsibility to provide services at the same level and to the same extent as those services would have been provided if the patient was in their own home.

e. Hospice A would ensure that mechanisms were in place to provide for coordination of all hospice
services provided to patients residing in the CAH. Hospice A would provide assistance as may be reasonable and necessary to the CAH to satisfy its responsibilities to implement the provisions of this Agreement.

3. Review of Hospice Provider A's Team Care Plan provided by CAH, dated 9/21/23, revealed Mobility and Safety Interventions included the following:

a. Alarms to couch and bed due to poor memory, increased weakness, and use of walker.
b. Voice monitor (device that amplifies sound so could hear couch and bed alarms when not in the room) added to the home so that family caregiver was able to move about freely and not have to watch the patient at all times.
Hospice care plan did not include a requirement to have a 1:1 sitter.

4. Review of Patient #1's medical record revealed:

a. On 9/25/23 at 1:47 PM, Patient #1 was admitted to the CAH. Patient #1 had a diagnosis of pancreatic cancer and was admitted for for hospice respite (short-term relief for in-home hospice caregivers).

b. On 9/27/23 at 3:30 AM, RN D documented that the bed alarm had sounded and they were now monitoring the patient 1:1.

c. On 9/27/23 at 4:25 PM, RN E documented that at 3:45 PM, CNA F heard Patient #1 hollering and found them sitting on the floor in their room.

d. On 9/27/1725 at 5:25 PM, x-ray results revealed Patient #1 had an age-indeterminate fracture of their right hip, recommend further imaging with Computed Tomography (CT) scan.

e. On 09/28/23 at 9:07 AM CT results revealed acute (recent) comminuted intertrochanteric fracture (right hip fracture).

f. On 9/28/23 at 10:32 AM (the morning after Patient #1 fell), SW G noted that Patient #1 had had a fall yesterday afternoon and they did have a right hip fracture. SW G was going to ask the hospice provider to provide a 1:1 sitter, and the CAH would provide a 1:1 sitter on 9/28/23 from 1:00 PM - 5:00 PM.

4. During an interview on 11/29/23 at 1:45 PM, the Quality Manager confirmed that they would consider a fall with injury an adverse event. When asked what timeframe they would consider as an "immediate" investigation and response, Quality Manager stated that they would address it as soon as they could. The Quality Manager explained that the CAH had a hospital wide fall prevention program and since this incident they had reviewed their audits and had started to now do random alarm checks. They had also implemented a program to put gold stars on the doors for patients who were identified as high risk for falls. The Quality Manager confirmed that they have been evaluating, but had not implemented, sitter training or video monitoring to be used to assist in fall prevention for some patients who were at high risk for falls.

5. During an interview on 11/28/23 at 11:30 PM, RN Inpatient Service Manager explained that a list of trained 1:1 sitters was now available to charge nurses, they were looking at developing a decision tree to assist RN's in making the decision for a 1:1 sitter. The RN Inpatient Service Manger confirmed that the deicison tree had not been put into place yet. They were also evaluating appropriate medical record documentation when a patient had a 1:1 sitter, but that too had not been put into place.

6. During an additional interview on 12/28/23 at 10:15 AM, the RN Inpatient Service Manger stated they tried to follow the hospice plan of care and continued to provide the same level of service as the patient had received at home. The RN Inpatient Service Manger explained that the hospice care plan was mostly used to assist the CAH in accepting or denying a referral. The RN Inpatient Service Manger CAH reported CAH staff do their best to align both the hospice and CAH care plans, but the hospice care plan was not accessible to direct care staff via their electronic medical record.

The RN Inpatient Service Manager was not aware that Patient #1's hospice care plan included a voice monitor. The RN Inpatient Service Manger explained that the CAH did not have a voice monitor, so this was not an intervention they could provide unless the hospice provider brought one to the CAH for use with the patient. The RN Inpatient Service Manger reported Hospice Provider A did not provide a voice monitor.

The RN Inpatient Service Manager did not think it was necessary to notify Hospice Provider A when RN D documented on 9/27/23 at 3:30 AM that CAH staff were now doing 1:1 monitoring of Patient #1. The RN Inpatient Service Manager explained that a hospice nurse came to the CAH every day to assess Patient #1, and CAH staff would have notified Hospice A when the hospice nurse came to assess the patient.

The RN Inpatient Service Manager stated that they felt Patient #1 needed a 1:1 sitter after they fell, and CAH staff did notify Hospice Provider A. The RN Inpatient Service Manger explained that during Patient #1's stay at the CAH, it would have been Hospice Provider A's responsibility to provide sitters. Initially the CAH provided the sitter and then they coordinated the sitter with Hospice Provider A.

6. During an interview on 11/28/23 at 2:00 PM, Chief Nursing Officer (CNO) explained that an RN should have implemented a 1:1 sitter if they did not feel that they could keep the patient safe. The CNO reported that they were developing the 1:1 sitter policy, but they currently did not have the policy in place.

7. During an additional interview on 12/28/23 at 10:00 AM, CNO confirmed that they should have been following the hospice plan of care but was unaware that the plan of care required Patient #1 to have a voice monitor. When asked whose responsibility it was to provide the voice monitor, CNO stated they didn't have one and thought it would be Hospice A's responsibility. However, the CNO reported they would need to review the contract between CAH and Hospice Provider A to confirm who was responsible for providing the voice monitor.

The CNO confirmed that they had not had any follow up discussions with Hospice Provider A to clarify any questions regarding required roles and responsibilities.