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Based on review of Governing Body Bylaws, medical records, staff interviews, policies and procedures and incident logs, it was determined that the Governing Body failed to ensure that the facility staff followed the hospital policies and procedures related to nursing assessments of one of 4 sampled patients (#1).

Cross refer to A-0063 as it relates to the Governing Body ' s failure to ensure safe and appropriate care for patients admitted.

Based on review of Governing Body Bylaws, medical records, staff interviews, policies and procedures and incident logs, it was determined that the Governing Body failed to ensure that the facility staff followed the hospital policies and procedures related to nursing assessments of one of 4 sampled patients (#1).

Findings:
A review of the facility's Governing Body Bylaws revealed that the supreme authority of the corporation and management of the affairs of the corporation shall be vested in the Board of Trustees; and all the powers, duties, and functions of the corporation conferred by the articles of incorporation, the Bylaws, state statutes or otherwise shall be exercised, performed and controlled by the Board of Trustees. The governing body of the corporation shall have supervision, control, and direction of the management, affairs, and property of the corporation: shall determine its policies or changes therein and shall actively prosecute its purposes and objectives.

A review of Patient (P), P#1 medical record revealed that P#1 presented to the facility's emergency department (ED) by EMS on 11/19/21 at 4:35 pm for orthostatic hypotension (low blood pressure when standing) due to decreased oral intake. P#1 had a past medical history of stroke (loss of blood flow to part of the brain), chronic kidney disease, arthritis (inflamed joints), and had recently developed dementia (loss of memory).

On 11/19/21 at 4:54 p.m. ED triage notes by registered nurse (RN) GG revealed that the EMS was called by P#1's home health RN stating that P#1's blood pressure dropped when standing to 70/40 mmHg. RN GG noted P#1 with a new diagnosis of dementia and had recently stayed at rehab for ambulation. RN GG documented that per EMS P#1 was a fall risk.

On 11/19/21 at 6:50 pm, P#1 ED's physical examination revealed that patient #1 was alert and disoriented.
A review of the admitting physician (MD AA) history and physical on 11/19/21 at 7.30 p.m. revealed that P#1 had a chronic sacral (bottom of the spine) ulcer (injuries to the skin and underlying tissue) present on admission. P#1 presented with low blood pressure and was reportedly not eating or drinking much. Further review of the history and physical note revealed that P#1 was recently discharged from a rehabilitation center after receiving physical therapy for frequent falls. P#1 was admitted on 11/19/21 at 9:04 p.m. to the facility for further evaluation and management of his low blood pressure and acute kidney injury.

P#1 medical record failed to reveal an initial nursing assessment including fall risk and skin assessment on admission to the facility.

On 11/20/21 at 12:10 am, RN CC documented that P#1 was agitated, confused, and attempted to get out of his bed twice. RN CC noted that P#1 was redirected and cleaned, P#1's door was open for 1:1 continuous monitoring, and RN CC notified the physician. MD AA ordered P#1 Haldol (antipsychotic) injection for agitation at 12:15 a.m. The order was administered by RN CC.

On 11/20/21 at 4:30 am, RN CC documented that P#1 attempted to get out of bed again and P#1 was able to be redirected back into bed.

On 11/20/21 at 7:53 am, RN CC noted that P#1 was found face down on the floor with a hematoma (collection of blood) on the left side of the forehead and blood noted on the floor. RN CC notified the physician, charge RN, and house supervisor. MD LL reassessed P#1 after the fall. MD LL documented that P#1 had a 2cm laceration (cut) to his left forehead with surrounding hematoma. P#1 was noted to be drowsy, oriented to self and place. MD LL ordered head and spine CT (computed tomography, diagnostic test to review changes inside the body), chest and pelvis X-ray, and a sitter for P#1 on 11/20/21 at 7:42 a.m.

The facility failed to provide documentation supporting a sitter was documented at P#1 ' s bedside.

A review of the head and spine CT report performed on 11/20/21 at 8:00 a.m. revealed a hematoma to the left side of the forehead, there was no intracranial (within the skull) hemorrhage or fractures (breaks in the bone) of the cervical spine.

P#1 ' s medical record failed to reveal an order for wound care and dietitian consultation.

A review of the facility's flowsheet assessment included the following:
On 11/20/21 at 8:45 a.m., P#1 was noted to be alert. At 9:00 a.m. P#1's ED fall risk assessment was completed. A review of the facility's flowsheet failed to reveal a fall risk assessment prior to P#1 falling. P#1 fell at the facility and was found face down on the floor at 7:40 a.m.

On 11/21/21 at 7:35 a.m., RN OO documented that P#1 was alert, oriented to person and place. RN OO noted P#1 with impaired vision, limited movement of the right and left lower extremity (legs). P#1 fall risk score was 22 (>10 high risks for falls), Braden scale ( scale for bed sore risk) score was 17(15 to 18 is mild risk, 12-14 is moderate risk, 10-12 is high risk, and 9 and above is very high risk). P#1 was noted to have forehead bruises. Further review failed to reveal pressure injury locations and interventions at this time.

On 11/22/21 at 8:00 a.m., facility flowsheet revealed that P#1 was alert, oriented to place, time and person. P#1 had impaired vision, limited movement of the right and left lower extremities. P#1's Braden scale score was 17, P#1 had forehead bruises. At 2:37 pm P#1 was noted to be oriented to person. Further review of the flowsheet failed to reveal a pressure injury at this time.

On 11/23/21 at 8:00 a.m., the facility's flowsheet revealed that P#1 was alert, oriented to person, place, and time. P#1's Braden score was 13. P#1 was noted to have limited movement of all limbs. P#1 had urinary incontinence. P#1's sacrum pressure injury was noted and dressed.

A review of the facility's care plan revealed that P#1's safety/fall plan started on 11/21/21. At 7:35 a.m. RN OO documented that P#1 verbalized understanding of falls education, precautions, prevention at home and while at the hospital.


A review of the facility's policy entitled "Fall Risk Assessment and Prevention," Policy #PS-45, last revised 1/2018, revealed that the facility's policy was to assess a patient for fall risk and implement fall prevention strategies to decrease the risk of patient falls.
The following procedure would be as follows:

1. A Registered Nurse (RN) would assess the patient for any fall risk on admission. The patient would be reassessed for a fall risk when a change in caregiver or patient condition may affect the fall risk.
2. An RN would implement a Fall Plan of Care for a patient at risk (score of 10 or greater).
Additional fall precautions measures would be implemented as clinically indicated by risk factors that were assessed. The patient would remain on fall precautions and fall prevention interventions until the fall risk score was nine or less on two consecutive assessments.
Bed alarms would remain on for patients with a score of 10 or greater. If the patient was out of bed for any reason (i.e., diagnostic test, up in a chair, etc.), the alarm could be disengaged and then reactivated when the patient returned to the bed.
3. During hand-off communication and unit-based "huddles, "healthcare team members would communicate the increased fall risk to other healthcare team members during hand-off communication and unit-based "huddles." The patient would be identified using yellow skid-proof socks, a yellow caution light or a yellow door sign, and a yellow armband.
4. The patient and the patient's family should receive education regarding fall risk and interventions. They should receive the patient/family education brochure on fall prevention in the purple admission packet. They should also receive ongoing education regarding interventions selected on the Fall Plan of Care.
5. An RN should document the fall risk assessment and progress towards the goals on the computerized documentation system and the designated computer downtime forms.
A change in the patient's condition that required modification of interventions should be documented in the Fall Plan of Care. In addition, patient/family education should be documented on the initiation of fall precautions and any changes in the fall prevention interventions.


A review of the facility's policy entitled "Assessment of the Patient," Policy #PE-05-01-, last revised 2/2017, revealed the following:
1. Assessment of the patient should be completed by a Licensed Health Care Professional.
a. The assessment should be completed upon entry into the system (within 12 hours of arrival to the inpatient unit).
b. Initial assessment should include the health history and physical assessment.
c. A Licensed Practical Nurse (LPN) could collect the nursing history, but the RN must review and co-sign.
2. Reassessment of the patient should be completed after non-invasive or invasive procedures, significant change in condition or diagnosis, and upon transfer to a different level of care or specialty unit.
3. Assessment of the patient should be completed for discharge planning needs.
a. The process should begin upon patient entry into the system.
b. Input from all disciplines involved in the patient's care was required.
c. The plan would be continually evaluated during the patient's hospitalization.


A review of the facility's policy entitled "Patient Rights and Responsibilities," Policy #R1-01-01, last revised 5/2013, revealed that any patient receiving medical, nursing, or healthcare of any kind or type within the facility would receive treatment in a respectful and safe environment.

A review of the facility's policy entitled "Patient Rights and Responsibilities," Policy #R1-01-01 Job Aid 1, last revised 5/2013 revealed that any patient receiving medical, nursing, or healthcare of any kind or type within the facility had the right to be free from the use of restraints and/or seclusion unless clinically necessary.


A review of the facility's policy entitled "Nursing Plan of Care," Policy #PS-51, last revised 8/2015, revealed that the Plan of Care (POC) would be individualized to meet the patient's needs based on data collected from the nursing assessment and would include involvement of the patient, family, and/or significant other. Care planning, treatment, and services would be collaborative and interdisciplinary.
The initiation of the POC would be as follows:

1. The patient would be assessed by a Registered Nurse (RN) on admission, and the POC selected would be based on an appropriate diagnosis. Co-morbidities and/or psychosocial issues would also be addressed.
2. The patient goals would be established.
3. Interventions would be documented and implemented to meet the individualized patient needs.
4. The patient would be reassessed at specified times based on the level of care or a significant change in the patient's condition.
5. The POC would be revised or reprioritized based on assessment or change in the patient's condition or diagnosis.
6. The established goals would be evaluated and documented.
7. The POC interventions would be continued, revised, or resolved to achieve the established goals.

A review of the facility's policy entitled, "Prevention of Pressure Injuries," Policy #PS-48, last revised 5/2018, revealed that:
1. A Registered Nurse (RN) would assess all skin surfaces on admission and every shift. Additionally, an RN would assess patient risk for developing pressure injury using the Braden Scale.
2. An RN would implement interventions for a patient with a Braden score greater than or equal to 18. An RN would also implement interventions for a patient with a Braden score of less than or equal to 17 or other high-risk indicators for impaired skin integrity.
3. An RN or Licensed Practical Nurse (LPN) would consult a dietician for patients with clinical indicators of high risk for impaired skin integrity.
An RN would document the Braden Score in the computerized documented system, the designated downtime forms, and/or the department-specific forms and flowsheets


A review of the facility's policy entitled "Treatment of Pressure Injuries," Policy #PS-49, last revised 1/2018, revealed the following:
1. A Registered Nurse (RN) should assess all skin surfaces on admission and every shift.
2. An RN should implement the wound care treatment guidelines by initiating the nurse-driven treatment protocol in the electronic medical record (EMR).
3. Consult the Wound Ostomy Continence (WOC) Nurse regarding altered skin integrity or additional assistance.
4. Consult a Dietician.
5. Document findings and treatment in the computerized documentation system or designated downtown forms.


A review of the facility's policy entitled "Maintenance of Skin Integrity," no date, revealed that the following items should be provided to patients to prevent skin breakdown:

1.Assess for a reddened area over bony prominences.
2.Minimize skin exposure to moisture from incontinence, perspiration, and wound drainage.
3.Instruct patient on cause and prevention of skin breakdown.
4.Keep skin clean, dry, and moisturized.
5.Use skin protective wipes or skin sealant under the tape with dressing change.
6.Limit the use of adhesive products on thin, fragile skin,
7.Maintain the head of the bed at the lowest degree of elevation.
8.Document any areas of redness that do not disappear within 30 minutes or any breaks in the skin.
9.Notify the Wound Care nurse when assistance was needed.



An interview with Registered Nurse (RN) II was conducted on 12/28/21 at 10:15 a.m. in the facility conference room. RN II explained that she had been a nurse for 34 years and was currently working as a Nurse Professional Development Specialist. She continued to say that her role involved Acute Care education. RN II stated that an initial skin assessment should be completed on all patients on admission. The skin assessment would be completed by two nurses and documented on the flowsheet in the electronic medical record. She further stated that an electronic documentation timeline should be completed. RN II said that even though a patient was on a bed hold in the Yellow Zone area of the emergency department (ED), once the patient was admitted to the facility, the patient should receive all required admission assessments and completed documentation. RN II explained that all staff was trained through behavioral health to be safety sitters. She continued to say that the facility would seek specifically trained staff to care and sit with a patient, but any staff member could be a safety sitter. She further explained that a safety sitter would document on a paper document and be scanned into the electronic medical record (EMR). RN II explained that the inpatient units used the Hester Davis Scale for fall risk assessments, but the ED used a different fall risk assessment scale. She further explained that fall education that was completed on admission, bed alarm documentation, and activity daily living (ADL's) (bathing, oral care, urinary incontinence care, etc.) should be documented on the flowsheet in the EMR.

An interview with Patient Safety Coordinator (PSC) JJ took place on 12/28/21 at 11:00 a.m. PSC JJ explained that she had been working at the facility for twelve (12) years. She explained that her job responsibilities included reviewing safer events reported within the hospital and conducting root cause analysis. PSC JJ said that every patient who presented to the facility was supposed to get a fall risk assessment. PSC JJ said the ED fall risk assessment is separated into a green and yellow status, she explained that a green status meant low fall risk and a yellow status indicated a patient is a high fall risk. PSC JJ explained that patients with high fall risk are expected to have a fall risk armband, wear a yellow sock, bed in the low position, side rails up, call light in place, and their rooms closer to the nursing station. PSC JJ said that the initial nursing assessment including a fall risk and skin assessment was supposed to be completed within 24 hours of admission. PSC JJ acknowledged there was no initial nursing assessment done for P#1 after admission. PSC JJ explained that cleaning up patient are carried out as needed but is supposed to be completed at least every 24 hours.


An interview was conducted with Medical Doctor (MD) AA on 12/28/21 at 2:10 pm. MD AA acknowledged that he remembered admitting P#1. MD AA explained that P#1 came in with hypotension, chronic sacral ulcer, acute kidney injury, and was recently diagnosed with dementia. MD AA said he guessed P#1 fell the next morning. MD AA explained that the nurse said P#1 was trying to get out of the bed. MD AA said that for a patient with a chronic sacral ulcer present on admission he would put an order for a wound care consult and the nurses on admission will do a skin assessment for the patient. MD AA further explained that a full assessment including a fall risk and skin assessment is done for all patients upon admission. MD AA explained that the patient is in the facility's holding area (yellow zone) when there is a volume surge. MD AA further explained that patients kept at the yellow zone are close to the nursing station where nurses have direct visual. MD AA explained that if a patient is trying to get out of the bed he would order a sitter, he further explained that chemical restraint is necessary if the patient is combative, swinging, and has become a threat to themselves or others. MD AA explained that patients with dementia may be verbally redirected but if they are swinging, they need a dose of medicine to help. MD AA explained that a nutritional or dietitian consult order is initiated on admission to the floor for a patient with a chronic sacral ulcer, he further explained that nurses will do the full assessment and can put in the order for a wound and nutritional consult. MD AA said that the wound care nurse would get an alert once they are consulted and somehow, she was not available to care for P#1.

An interview with Registered Nurse (RN) FF was conducted on 12/28/21 at 2:35 p.m. in the facility conference room. RN FF explained that for the past 20 months, she had held the position of Director of Nursing for Emergency Services. She continued to say that she had been an RN for 20 years and most of her nursing background was in emergency medicine. RN FF explained that the emergency department (ED) held an eight-bed Yellow Zone pod. She continued to explain that with the surge of COVID-19, it had become necessary to keep patients admitted to the facility in the ED on a bed hold until an inpatient bed became available. The Yellow Zone would house those patients on an inpatient bed hold, and it was not unusual to have ED patients in the Yellow Zone simultaneously. RN FF stated that the preference was to have an inpatient nurse come to the ED Yellow Zone to provide care to those patients on an inpatient bed hold, but that was not always the case, and an ED nurse would be required to provide care for the inpatients currently on a bed hold in the ED. She continued to explain that at one point that there was a core group of nurses who had been cross-trained to care for the inpatients in the ED, but they were no longer available. RN FF further stated that not all ED nurses were trained on the procedures for new admissions, including skin assessments. But her expectations were that the ED nurses would have the basic knowledge to provide care for those inpatients. RN FF said that some patients received focus assessments and that assessing a patient and documentation would be based on a patient's condition and length of stay. She continued to say that the ED nurses were trained to apply dressings to pressure wounds and her expectation was that the ED nurses would document their actions in the patient's medical record. She stated that the ED assessed patients for falls, and they were given a green (low risk) or yellow (high risk). Green status included ensuring that the patient's call light was within reach and other items the patient may need. A yellow status included a yellow patient armband, call light within reach, yellow non-slip socks, bed rails up in a locked position, and hourly rounding on the patient. If a patient received a chemical restraint, RN FF stated that no additional fall prevention measures would be implemented. RN FF continued to say that activity daily living (ADL's) which included oral hygiene and bathing, could easily get missed for inpatients that were on a bed hold in the ED because it was not commonly performed in the ED. Her expectation was that patient hygiene would be addressed once a shift. RN FF further stated that she expected that ED staff keep a patient clean and dry if they were incontinent.

A follow-up interview was conducted with RN FF on 12/29/21 at 2:10 p.m. in the yellow zone of the Emergency Department. RN FF stated that the ED did not have the Wound Care Resource Guide; it was only inpatient. RN FF said that if a 1:1 safety sitter was ordered, there was never an incident that a sitter was not provided. She continued to say that the ED nurses at no time would be required to provide care for other patients while acting as a 1:1 safety sitter.


A phone interview with the Registered Nurse (RN) CC was conducted on 12/28/21 at 4:25 p.m., in the facility conference room. RN CC stated that she was an agency nurse who worked in the emergency department (ED). She said that she recalled P#1. She continued to say that P#1 was seen in the ED due to orthostatic hypotension (decrease in blood pressure when assuming an upright position). She recalled that he was recently diagnosed with dementia and was alert and oriented x2 (person and place) and sometimes x3 (person, place, time). RN CC continued saying that P#1 was agitated throughout the night, and on multiple occasions, he tried to leave his room and stated that he wanted to go home. RN CC said that she contacted his provider to get some medication to help him rest, and P#1 slept a good portion of the night after receiving the medication. She stated that P#1 had a few incontinent accidents during the night, and RN CC recalled cleaning P#1 up afterward. RN CC stated that she did not recall seeing any significant wounds when providing incontinent care. She explained that she provided care to P#1 while he was a patient in the ED and continued to do so once he was admitted to the facility. The facility did not have an inpatient bed available, so P#1 remained on a bed hold in the ED. RN CC explained that P#1 was moved to the Yellow Zone in the ED the following morning, and he received a different nurse once he was moved. RN CC continued to explain that the Yellow Zone was an area in the ED where patients waiting for a bed on an inpatient unit could be held until the inpatient bed became available. She further stated that an incident involving P#1 occurred the morning after his admission. RN CC said she was on her way to P#1's room for bedside shift report, and when she entered, she found P#1 on the floor. She stated that she assisted P#1 onto his bed and provided a neuro exam. She continued to say that P#1 had sustained a bruise to his left temple. She further said that P#1 was on a blood thinner and had a history of a stroke. RN CC stated that she notified the charge nurse, house supervisor, and P#1's provider. P#1 was oriented but seemed lethargic. A Computerized Tomography (CT) scan (x-ray images of bones, blood vessels, and soft tissues) was ordered. RN CC stated that P#1 had fall precautions (bed rails up, yellow non-slip socks, call light within reach) in place prior to P#1's fall. She further stated that she did not recall if P#1 had a Fall Risk Assessment completed. She explained that the Fall Risk Assessment was typically done during triage. RN CC said that she had completed the Fall Risk Assessments on occasion after a patient had been triaged and would specify the assessment in her nursing notes. RN CC said that she was unaware that she needed to document P#1's fall on the Post Fall Documentation Flowsheet. RN CC said P#1 did not have a safety sitter. She stated that she tried to provide one-on-one observation for P#1. She explained that she propped her computer by P#1's doorway and watched P#1 while caring for her other patients. RN CC explained that if a patient were admitted to the facility and was on a bed hold in the ED, she would continue to chart using the ED charting system. She continued to say that she did not have a lot of knowledge about the required inpatient documentation that needed to be completed. RN CC stated that the ED performed their nursing assessments differently than the inpatient units.

An interview with Wound Care Ostomy Nurse (WCON) KK was conducted on 12/28/21 at 4:50 p.m. in the facility conference room. WCON KK explained that she had been a WCON for two and half years. WCON KK explained that when a wound care order was initiated, it would populate into the new consult list that she printed daily. She further stated that she would see a patient with a new consult within 72 hours and sometimes the following day. WCON KK said that new consults and wound care were not provided on the weekends. She explained that she would assess the patient's wounds, clean the wound bed, and take photos of the wounds when she met with a patient. Then, she would decide on the best treatment, and if she had everything at the bedside to treat the wounds, she would perform it herself. If a medication were not available and needed to be ordered from the pharmacy, she would place specific instructions into the patient's medical record. Then, the patient's bedside nurse would provide the care and treatment. WCON KK said that newly hired nurses shadowed her, and she offered an overview of wound care. She explained that each unit had a Wound Care Treatment Resource Book that contained the Wound Care policies and Wound Care Treatment Guidelines with pictures to assist the bedside nurse. WCON KK stated she was unaware if the ED had a copy of the Wound Care Treatment Resource Guide. WCON KK further stated that she expected that bedside nurses could provide standard wound care. WCON KK said that P#1's name sounded familiar but could not recall any details about P#1

A telephone interview with Registered Nurse (RN) GG took place on 12/28/21 at 5:20 p.m. RN GG explained that he works in the emergency department at the facility and could not recall anything about P#1. When asked about fall risk assessment, RN GG said that assessing a patient at the facility's ED for falls typically depends on how sick was the patient. RN GG explained that in a perfect world they were supposed to do a fall risk assessment but if the patient is unstable they needed to do blood works and stabilize the patient. RN GG explained that fall risk assessment is part of triage assessment but this is not what they can complete, because they are trying to help nurses that are overwhelmed. RN GG said that the emergency rooms are chaotic and ER patients are not stable. RN GG further explained that he would stabilize the patient's blood pressure and prioritize which patient is medically unstable over assessing for fall risks. RN GG said fall risk assessment will be done on the inpatient admission. RN GG said If a patient is going to be admitted at the facility a lot of stuff doesn't get done at the ED because they are done upstairs (inpatient unit). RN GG explained that since the beginning of COVID the yellow zone had been used as a patient hold, he further explained that since the covid surge it is not uncommon to have emergency and inpatient mix together at the ED. RN GG explained that he could not remember any training on how to care for inpatient admits present at the ED. RN GG said that he could not remember how much of a fall risk was P#1, he further said that if the EMS said P#1 was a fall risk maybe they made a mistake or probably P#1 was no longer a fall risk once he got to the hospital. When asked if he could consider a fall risk assessment for a patient on chemical restraint, RN GG said that if the patient was on restraints that means probably the patient was combative and it was not possible to assess the patient for falls. RN GG said that since the vaccine mandate the facility had lost a lot of staff and staffing had become a problem.

An interview with the Director of Patient Safety and Quality (DPS) MM took place on 12/29/21 at 10:47 a.m. DPS MM explained that she had been working at the facility for 13 months and her job roles included patient safety and quality oversight. DPS MM explained that the hospital had a fall improvement committee and their responsibility was to trend fall data, looking for trends and measures to reduce falls. DPS MM further explained that before the pandemic the committee intended to meet on monthly basis but unfortunately since July 2021 the facility had not done any trending on falls. DPS MM said she was not aware of any quality improvement involving actively tracking pressure injuries within the facility. DPS MM explained that safety sitters are not required to complete any documentation, she further explained that if the sitter is for behavioral health patients they are required to do documentation.


An interview was conducted with Registered Nurse (RN) HH on 12/29/21 at 11:18 a.m. in the facility's conference room. RN HH stated that she was the Executive Director of Nursing Inpatient and Women's Health for two years. RN HH said that she was unaware of any details that involved P#1. She explained that a patient should receive a head-to-toe assessment, including a skin assessment that two nurses completed on admission. In addition, the database questionnaire in the medical record should be completed and the Hester Davis Fall Assessment. If the patient were considered high risk, it would be flagged in the medical record. The patient would receive a yellow fall armband, yellow non-skid socks, the bed alarm would be on, and the call light would remain within reach. The patient would also be checked on more frequently, and the patient and family (if present) would be educated. RN HH said that if a nurse found a wound during an initial assessment, it should be documented that it was present on admission in the patient's medical record. The nurse should also request a wound care consult and consult the Wound Care Resource Guide for treatment. RN HH said these items should be done for all new inpatient admissions regardless of where they were in the facility. She continued to say that she expected that all new inpatients admissions would receive the same care they would receive on an inpatient unit if they were on a bed hold in the emergency department. RN HH explained that the yellow zone in the ED was used when there was a surge of patients in the ED and patients on a bed hold. If staffing were available, an acute care nurse would provide the care for the inpatients on a bed hold in the ED. If an acute care nurse were unavailable, an ED nurse would continue to provide patient care. RN HH said that if a 1:1 safety sitter was ordered for a patient; a nurse was not expected to provide the services while still providing care to other patients. She explained that a unit secretary or care partner would sit with the patient.

An interview took place with Registered Nurse (RN) DD on 12/29/21 at 2:21 p.m. in the conference room. RN DD recalled P#1. RN DD explained that she received P#1 in the morning around 7:30 a.m. on 11/20/21. RN DD said she and RN CC went to P#1's room and saw P#1 on the floor with little abrasion on his forehead. RN DD said there was small blood on P#1's gown but no profuse bleeding or nothing needed to repair. RN DD explained that she notified the provider and because P#1 was on a blood thinner, a head CT scan had to be done. RN DD said a CT scan was done and the result was normal. RN DD explained that P#1 was a little fatigue but there was nothing unusual on assessment. RN DD explained that she completed a fall risk assessment on P#1 on her shift and wore a yellow sock and armband on the patient. RN DD said P#1 had no yellow sock and band prior to falling. RN DD explained that at the time she received P#1 did not have a sitter, but they were able to pull a care technician to sit with the patient on her shift. RN DD said that when a sitter is assigned to a patient the sitter was supposed to be with the patient line of sight at all times. RN DD acknowledged there had been two occasions in the last two months where they needed a sitter, but none was available. RN DD explained that the nurses had to keep th

Based on review of incident reports, staff interviews, quality and fall committee meeting minutes, it was determined that the facility failed to establish an ongoing program that measure, analyze, and track falls and pressure injuries in all units.

Cross refer to A-0321 as it relates to the facility's failure to integrate an appropriate Quality Assurance Performance Improvement (QAPI) plan that address falls and skin breakdown on all units of the facility.

Based on a review of incident logs, interviews with staff, a review of the facility ' s Quality Performance Improvement plan FY21, and facility meeting minutes, it was determined the facility failed to have an integrated QAPI (quality assurance and performance improvement) established in a manner that takes into account unique situations and significant differences in patient p

A review of the incident log from 7/1/21 to 12/28/21 revealed that there were 20 incidents of falls at the ED and 16 incidents of pressure injury. Further review of the log revealed that on 11/20/21 at 7:40 am. P#1 was noted to have fallen and was found on the ground. On 11/22/21 at 5:09 am P#1 was noted to have a pressure injury.

An interview with the Director of Patient Safety and Quality (DPS) MM took place on 12/29/21 at 10:47 a.m. DPS MM explained that she had been working at the facility for 13 months and her job roles included patient safety and quality oversight. DPS MM explained that the hospital had a fall improvement committee, and their responsibility was to trend fall data, looking for trends and measures to reduce falls. DPS MM further explained that before the pandemic the committee intended to meet on monthly basis but unfortunately since July 2021 the facility had not done any trending on falls. DPS MM said she was not aware of any facility's quality improvement data and measures to actively track pressure injuries.

A review of the facility's Quality Performance Improvement Plan FY21 revealed that the plan is to set forth functional strategies to provide a planned, systematic, organizational-wide approach in designing processes.

A review of the facility's fall committee meeting minutes revealed that the facility's fall performance improvement team meet three times in the last 12 months ( 2/4/21, 3/24/21, and 8/23/21).

A review of the facility's quality review committee meeting minutes from February 4, 2021 to November 4,2021 revealed that the facility is actively tracking Central Line- Associated Bloodstream Infection (CLABSI), Catheter Associated Urinary Tract Infection (CAUTI), hand hygiene. Further review of the quality review committee meeting minutes revealed that on 3/4/21, 8/5/21, 10/7/21 the committee discussed data measures to reduce falls in the ED. The meeting minutes failed to review discussion and data measures to reduce falls in the other units at the facility. A review of the quality review committee meeting minutes failed to reveal that the facility is actively tracking pressure injuries.

Based on review of medical record, policies and procedures, staff interviews, observations, incident reports, quality and fall committee meeting minutes, it was determined the facility failed to provide adequate nursing services to one of 4 sampled patients (P#1). Specifically, the facility failed to provide an initial nursing assessment including an assessment of all P#1's skin surfaces (head to toe), fall risk assessment on admission. The facility failed to meet the patient's (P#1) needs by not providing and implementing a fall plan of care, educating P#1 and/or P#1's family regarding fall risk and interventions, assessing and implementing fall prevention strategies to decrease the risk of patient falls prior to P#1 falling at the facility.

Cross refer to A-0392 as it relates to the facility ' s failure to provide adequate delivery of care for one of 4 sampled patients (P#1).

Cross refer to A-0396 to the facility ' s failure to provide an adequate nursing plan of care for one of 4 sampled patients (P#1).

Based on review of medical record, policies and procedures ,staff interviews, observations, incident reports,quality and fall committee meeting minutes, it was determined the facility failed to provide appropriate nursing assessments to one of 4 sampled patients (P#1). Specifically, the facility failed to provide an initial nursing assessment including an assessment of all P#1's skin surfaces (head to toe), fall risk assessment on admission. The facility failed to meet the patient's (P#1) needs by not providing and implementing a fall plan of care, educating P#1 and/or P#1's family regarding fall risk and interventions, assessing and implementing fall prevention strategies to decrease the risk of patient falls prior to P#1 falling at the facility.

Findings:

A review of Patient (P), P#1 medical record revealed that P#1 presented to the facility's emergency department (ED) by EMS on 11/19/21 at 4:35 pm for orthostatic hypotension (low blood pressure when standing) due to decreased oral intake. P#1 had a past medical history of stroke (loss of blood flow to part of the brain), chronic kidney disease, arthritis (inflamed joints), and had recently developed dementia (loss of memory).

On 11/19/21 at 4:54 p.m., ED triage notes by RN GG revealed that the EMS was called by P#1's home health RN stating that P#1's blood pressure dropped when standing to 70/40 mmHg. RN GG noted P#1 with a new diagnosis of dementia and had recently stayed at rehab for ambulation. RN GG documented that per EMS P#1 was a fall risk.

On 11/19/21 at 6:50 p.m., P#1 ED's physical examination revealed that patient #1 was alert and disoriented.
A review of the admitting physician (MD AA) history and physical on 11/19/21 at 7.30 p.m. revealed that P#1 had a chronic sacral (bottom of the spine) ulcer (injuries to the skin and underlying tissue) present on admission. P#1 presented with low blood pressure and was reportedly not eating or drinking much. Further review of the history and physical note revealed that P#1 was recently discharged from a rehabilitation center after receiving physical therapy for frequent falls. P#1 was admitted on 11/19/21 at 9:04 p.m. to the facility for further evaluation and management of his low blood pressure and acute kidney injury.

P#1 medical record failed to reveal an initial nursing assessment including fall risk and skin assessment on admission to the facility.

On 11/20/21 at 12:10 a.m., RN CC documented that P#1 was agitated, confused, and attempted to get out of his bed twice. RN CC noted that P#1 was redirected and cleaned, P#1's door was open for 1:1 continuous monitoring, and RN CC notified the physician. MD AA ordered P#1 Haldol (antipsychotic) injection for agitation at 12:15 a.m. The order was administered by RN CC.

On 11/20/21 at 4:30 a..,m RN CC documented that P#1 attempted to get out of bed again and P#1 was able to be redirected back into bed.

On 11/20/21 at 7:53 a.m., RN CC noted that P#1 was found face down on the floor with a hematoma (collection of blood) on the left side of the forehead and blood noted on the floor. RN CC notified the physician, charge RN, and house supervisor. MD LL reassessed P#1 after the fall. MD LL documented that P#1 had a 2cm laceration (cut) to his left forehead with surrounding hematoma. P#1 was noted to be drowsy, oriented to self and place. MD LL ordered head and spine CT (computed tomography, diagnostic test to review changes inside the body), chest and pelvis X-ray, and a sitter for P#1 on 11/20/21 at 7:42 a.m.

The facility failed to provide documentation supporting a sitter was documented at P#1 ' s bedside.

A review of the head and spine CT report performed on 11/20/21 at 8:00 a.m. revealed a hematoma to the left side of the forehead, there was no intracranial (within the skull) hemorrhage or fractures (breaks in the bone) of the cervical spine.

P#1 ' s medical record failed to reveal an order for wound care and dietitian consultation.

A review of the facility's flowsheet assessment included the following:
On 11/20/21 at 8:45 a.m., P#1 was noted to be alert. At 9:00 a.m. P#1's ED fall risk assessment was completed. A review of the facility's flowsheet failed to reveal a fall risk assessment prior to P#1 falling. P#1 fell at the facility and was found face down on the floor at 7:40 a.m.

On 11/21/21 at 7:35 a.m., RN OO documented that P#1 was alert, oriented to person and place. RN OO noted P#1 with impaired vision, limited movement of the right and left lower extremity (legs). P#1 fall risk score was 22 (>10 high risks for falls), Braden scale ( scale for bed sore risk) score was 17(15 to 18 is mild risk, 12-14 is moderate risk, 10-12 is high risk, and 9 and above is very high risk). P#1 was noted to have forehead bruises. Further review failed to reveal pressure injury locations and interventions at this time.

On 11/22/21 at 8:00 a.m., facility flowsheet revealed that P#1 was alert, oriented to place, time and person. P#1 had impaired vision, limited movement of the right and left lower extremities. P#1's Braden scale score was 17, P#1 had forehead bruises. At 2:37 pm P#1 was noted to be oriented to person. Further review of the flowsheet failed to reveal a pressure injury at this time.

On 11/23/21 at 8:00 a.m., the facility's flowsheet revealed that P#1 was alert, oriented to person, place, and time. P#1's Braden score was 13. P#1 was noted to have limited movement of all limbs. P#1 had urinary incontinence. P#1's sacrum pressure injury was noted and dressed.

A review of the facility's care plan revealed that P#1's safety/fall plan started on 11/21/21. At 7:35 a.m. RN OO documented that P#1 verbalized understanding of falls education, precautions, prevention at home and while at the hospital.

A review of the facility's care coordination initial assessment revealed that P#1's discharge planning began on 11/20/21. At 12:08 p.m., SW EE documented that P#1 was anticipated to be discharged back home with home health service when medically ready. SW EE noted that P#1 had bowel and urinary incontinence and needed moderate assistance.

On 11/22/21 at 5:48 p.m., SW EE noted that she spoke with P#1's spouse and P#1's spouse declined hospice. P#1's spouse asked that P#1 return home with home health.
A review of the discharged information revealed that P#1 was discharged from the facility on 11/23/21 at 7:21 p.m. to a skilled nursing facility. P#1 discharge instruction, medications, follow-up information were completed. P#1 was noted to be stable on discharge.

A review of the Wound Care Consult request log dated 11/19/21 at 10:33 a.m. to 11/23/21 at 9:04 a.m. revealed that P#1 was on the Wound Care schedule on 11/22/21. Additionally, P#1's name was noted on the Wound Care schedule dated 11/23/21 but was not assessed due to the patient's discharge from the facility.

A review of the facility's policy entitled "Fall Risk Assessment and Prevention," Policy #PS-45, last revised 1/2018, revealed that the facility's policy was to assess a patient for fall risk and implement fall prevention strategies to decrease the risk of patient falls.
The following procedure would be as follows:

1. A Registered Nurse (RN) would assess the patient for any fall risk on admission. The patient would be reassessed for a fall risk when a change in caregiver or patient condition may affect the fall risk.
2. An RN would implement a Fall Plan of Care for a patient at risk (score of 10 or greater).
Additional fall precautions measures would be implemented as clinically indicated by risk factors that were assessed. The patient would remain on fall precautions and fall prevention interventions until the fall risk score was nine or less on two consecutive assessments.
Bed alarms would remain on for patients with a score of 10 or greater. If the patient was out of bed for any reason (i.e., diagnostic test, up in a chair, etc.), the alarm could be disengaged and then reactivated when the patient returned to the bed.
3. During hand-off communication and unit-based "huddles, "healthcare team members would communicate the increased fall risk to other healthcare team members during hand-off communication and unit-based "huddles." The patient would be identified using yellow skid-proof socks, a yellow caution light or a yellow door sign, and a yellow armband.
4. The patient and the patient's family should receive education regarding fall risk and interventions. They should receive the patient/family education brochure on fall prevention in the purple admission packet. They should also receive ongoing education regarding interventions selected on the Fall Plan of Care.
5. An RN should document the fall risk assessment and progress towards the goals on the computerized documentation system and the designated computer downtime forms.
A change in the patient's condition that required modification of interventions should be documented in the Fall Plan of Care. In addition, patient/family education should be documented on the initiation of fall precautions and any changes in the fall prevention interventions.


A review of the facility's policy entitled "Assessment of the Patient," Policy #PE-05-01-, last revised 2/2017, revealed the following:
1. Assessment of the patient should be completed by a Licensed Health Care Professional.
a. The assessment should be completed upon entry into the system (within 12 hours of arrival to the inpatient unit).
b. Initial assessment should include the health history and physical assessment.
c. A Licensed Practical Nurse (LPN) could collect the nursing history, but the RN must review and co-sign.
2. Reassessment of the patient should be completed after non-invasive or invasive procedures, significant change in condition or diagnosis, and upon transfer to a different level of care or specialty unit.
3. Assessment of the patient should be completed for discharge planning needs.
a. The process should begin upon patient entry into the system.
b. Input from all disciplines involved in the patient's care was required.
c. The plan would be continually evaluated during the patient's hospitalization.


A review of the facility's policy entitled "Patient Rights and Responsibilities," Policy #R1-01-01, last revised 5/2013, revealed that any patient receiving medical, nursing, or healthcare of any kind or type within the facility would receive treatment in a respectful and safe environment.

A review of the facility's policy entitled "Patient Rights and Responsibilities," Policy #R1-01-01 Job Aid 1, last revised 5/2013 revealed that any patient receiving medical, nursing, or healthcare of any kind or type within the facility had the right to be free from the use of restraints and/or seclusion unless clinically necessary.


A review of the facility's policy entitled "Nursing Plan of Care," Policy #PS-51, last revised 8/2015, revealed that the Plan of Care (POC) would be individualized to meet the patient's needs based on data collected from the nursing assessment and would include involvement of the patient, family, and/or significant other. Care planning, treatment, and services would be collaborative and interdisciplinary.
The initiation of the POC would be as follows:

1. The patient would be assessed by a Registered Nurse (RN) on admission, and the POC selected would be based on an appropriate diagnosis. Co-morbidities and/or psychosocial issues would also be addressed.
2. The patient goals would be established.
3. Interventions would be documented and implemented to meet the individualized patient needs.
4. The patient would be reassessed at specified times based on the level of care or a significant change in the patient's condition.
5. The POC would be revised or reprioritized based on assessment or change in the patient's condition or diagnosis.
6. The established goals would be evaluated and documented.
7. The POC interventions would be continued, revised, or resolved to achieve the established goals.

A review of the facility's policy entitled, "Prevention of Pressure Injuries," Policy #PS-48, last revised 5/2018, revealed that:
1. A Registered Nurse (RN) would assess all skin surfaces on admission and every shift. Additionally, an RN would assess patient risk for developing pressure injury using the Braden Scale.
2. An RN would implement interventions for a patient with a Braden score greater than or equal to 18. An RN would also implement interventions for a patient with a Braden score of less than or equal to 17 or other high-risk indicators for impaired skin integrity.
3. An RN or Licensed Practical Nurse (LPN) would consult a dietician for patients with clinical indicators of high risk for impaired skin integrity.
An RN would document the Braden Score in the computerized documented system, the designated downtime forms, and/or the department-specific forms and flowsheets


A review of the facility's policy entitled "Treatment of Pressure Injuries," Policy #PS-49, last revised 1/2018, revealed the following:
1. A Registered Nurse (RN) should assess all skin surfaces on admission and every shift.
2. An RN should implement the wound care treatment guidelines by initiating the nurse-driven treatment protocol in the electronic medical record (EMR).
3. Consult the Wound Ostomy Continence (WOC) Nurse regarding altered skin integrity or additional assistance.
4. Consult a Dietician.
5. Document findings and treatment in the computerized documentation system or designated downtown forms.


A review of the facility's policy entitled "Maintenance of Skin Integrity," no date, revealed that the following items should be provided to patients to prevent skin breakdown:

1.Assess for a reddened area over bony prominences.
2.Minimize skin exposure to moisture from incontinence, perspiration, and wound drainage.
3.Instruct patient on cause and prevention of skin breakdown.
4.Keep skin clean, dry, and moisturized.
5.Use skin protective wipes or skin sealant under the tape with dressing change.
6.Limit the use of adhesive products on thin, fragile skin,
7.Maintain the head of the bed at the lowest degree of elevation.
8.Document any areas of redness that do not disappear within 30 minutes or any breaks in the skin.
9.Notify the Wound Care nurse when assistance was needed.

A review of the facility's policy entitled "Utilization of Safety Sitters," Policy #PS-72, last revised 6/2018, revealed that the policy's purpose was to ensure safe, quality care for patients receiving direct observation via "safety" sitters to prevent interruption of necessary medical therapies.
The procedure would be as follows:

1. Assess and identify the reason for behavior requiring intervention to reduce safety risks.
2. Initiate Safe Room Guidelines.
a. A sitter would be assigned to the patient.
3. Initiate Use of Safety Sitter Assessment Tool.
a. If possible, move the patient to a room closer to the nurse's station.
b. Ensure bed alarms were utilized.
c. Attempt diversion activities.
4. Complete Safety Sitter Request Form
a. Document process, verification of alternative diversion activities, family education, etc.
b. Retain form for audits.
5. Educate the family regarding the safety sitter role.
a. Include the patient's family/support system in the plan of care.
6. Notify the on-site staffing office of the approved need for a safety sitter.
7. Verify the sitter's presence and monitoring ratio by a note in the medical record.
a. Once the sitter arrived at the unit, the RN would document their presence and ratio of patient monitoring.
b. Appropriate forms were completed as assigned.
8. Provide hand-off to safety sitter assigned to the patient utilizing the Safety Communication Hand-Off Tool.
a. Unit staff would provide relief for safety sitters for breaks as needed.
b. Ensure continuity of observation to ensure safety and prevent falls, elopement, etc.
9. Reassess the need for a safety sitter every shift change.
The safety sitter utilization was a supplemental layer of safety and would not replace the care measures/observations by nursing, support, and/or the medical staff. In addition, the safety sitter needs were allocated based on the need and resources at the facility


An interview with Registered Nurse (RN) II was conducted on 12/28/21 at 10:15 a.m. in the facility conference room. RN II explained that she had been a nurse for 34 years and was currently working as a Nurse Professional Development Specialist. She continued to say that her role involved Acute Care education. RN II stated that an initial skin assessment should be completed on all patients on admission. The skin assessment would be completed by two nurses and documented on the flowsheet in the electronic medical record. She further stated that an electronic documentation timeline should be completed. RN II said that even though a patient was on a bed hold in the Yellow Zone area of the emergency department (ED), once the patient was admitted to the facility, the patient should receive all required admission assessments and completed documentation. RN II explained that all staff was trained through behavioral health to be safety sitters. She continued to say that the facility would seek specifically trained staff to care and sit with a patient, but any staff member could be a safety sitter. She further explained that a safety sitter would document on a paper document and be scanned into the electronic medical record (EMR). RN II explained that the inpatient units used the Hester Davis Scale for fall risk assessments, but the ED used a different fall risk assessment scale. She further explained that fall education that was completed on admission, bed alarm documentation, and activity daily living (ADL's) (bathing, oral care, urinary incontinence care, etc.) should be documented on the flowsheet in the EMR.

An interview with Patient Safety Coordinator (PSC) JJ took place on 12/28/21 at 11:00 a.m. PSC JJ explained that she had been working at the facility for twelve (12) years. She explained that her job responsibilities included reviewing safer events reported within the hospital and conducting root cause analysis. PSC JJ said that every patient who presented to the facility was supposed to get a fall risk assessment. PSC JJ said the ED fall risk assessment is separated into a green and yellow status, she explained that a green status meant low fall risk and a yellow status indicated a patient is a high fall risk. PSC JJ explained that patients with high fall risk are expected to have a fall risk armband, wear a yellow sock, bed in the low position, side rails up, call light in place, and their rooms closer to the nursing station. PSC JJ said that the initial nursing assessment including a fall risk and skin assessment was supposed to be completed within 24 hours of admission. PSC JJ acknowledged there was no initial nursing assessment done for P#1 after admission. PSC JJ explained that cleaning up patient are carried out as needed but is supposed to be completed at least every 24 hours.


An interview was conducted with Medical Doctor (MD) AA on 12/28/21 at 2:10 pm. MD AA acknowledged that he remembered admitting P#1. MD AA explained that P#1 came in with hypotension, chronic sacral ulcer, acute kidney injury, and was recently diagnosed with dementia. MD AA said he guessed P#1 fell the next morning. MD AA explained that the nurse said P#1 was trying to get out of the bed. MD AA said that for a patient with a chronic sacral ulcer present on admission he would put an order for a wound care consult and the nurses on admission will do a skin assessment for the patient. MD AA further explained that a full assessment including a fall risk and skin assessment is done for all patients upon admission. MD AA explained that the patient is in the facility's holding area (yellow zone) when there is a volume surge. MD AA further explained that patients kept at the yellow zone are close to the nursing station where nurses have direct visual. MD AA explained that if a patient is trying to get out of the bed he would order a sitter, he further explained that chemical restraint is necessary if the patient is combative, swinging, and has become a threat to themselves or others. MD AA explained that patients with dementia may be verbally redirected but if they are swinging, they need a dose of medicine to help. MD AA explained that a nutritional or dietitian consult order is initiated on admission to the floor for a patient with a chronic sacral ulcer, he further explained that nurses will do the full assessment and can put in the order for a wound and nutritional consult. MD AA said that the wound care nurse would get an alert once they are consulted and somehow, she was not available to care for P#1.

An interview with Registered Nurse (RN) FF was conducted on 12/28/21 at 2:35 p.m. in the facility conference room. RN FF explained that for the past 20 months, she had held the position of Director of Nursing for Emergency Services. She continued to say that she had been an RN for 20 years and most of her nursing background was in emergency medicine. RN FF explained that the emergency department (ED) held an eight-bed Yellow Zone pod. She continued to explain that with the surge of COVID-19, it had become necessary to keep patients admitted to the facility in the ED on a bed hold until an inpatient bed became available. The Yellow Zone would house those patients on an inpatient bed hold, and it was not unusual to have ED patients in the Yellow Zone simultaneously. RN FF stated that the preference was to have an inpatient nurse come to the ED Yellow Zone to provide care to those patients on an inpatient bed hold, but that was not always the case, and an ED nurse would be required to provide care for the inpatients currently on a bed hold in the ED. She continued to explain that at one point that there was a core group of nurses who had been cross-trained to care for the inpatients in the ED, but they were no longer available. RN FF further stated that not all ED nurses were trained on the procedures for new admissions, including skin assessments. But her expectations were that the ED nurses would have the basic knowledge to provide care for those inpatients. RN FF said that some patients received focus assessments and that assessing a patient and documentation would be based on a patient's condition and length of stay. She continued to say that the ED nurses were trained to apply dressings to pressure wounds and her expectation was that the ED nurses would document their actions in the patient's medical record. She stated that the ED assessed patients for falls, and they were given a green (low risk) or yellow (high risk). Green status included ensuring that the patient's call light was within reach and other items the patient may need. A yellow status included a yellow patient armband, call light within reach, yellow non-slip socks, bed rails up in a locked position, and hourly rounding on the patient. If a patient received a chemical restraint, RN FF stated that no additional fall prevention measures would be implemented. RN FF continued to say that activity daily living (ADL's) which included oral hygiene and bathing, could easily get missed for inpatients that were on a bed hold in the ED because it was not commonly performed in the ED. Her expectation was that patient hygiene would be addressed once a shift. RN FF further stated that she expected that ED staff keep a patient clean and dry if they were incontinent.

A follow-up interview was conducted with RN FF on 12/29/21 at 2:10 p.m. in the yellow zone of the Emergency Department. RN FF stated that the ED did not have the Wound Care Resource Guide; it was only inpatient. RN FF said that if a 1:1 safety sitter was ordered, there was never an incident that a sitter was not provided. She continued to say that the ED nurses at no time would be required to provide care for other patients while acting as a 1:1 safety sitter.

An interview was conducted with the Social worker (SW) EE on 12/28/21 at 3:43 pm. SW EE explained that could not recall the patient. SW EE explained that they typically conduct a discharge planning upon patient admission. SW EE said they would see the patient within 24 hours. SW EE said the care coordinator would speak with the patient or patient's family member and determine the discharge plan based on the patient medical condition. SW EE explained that discharged planning is carried out regardless of a patient being in the facility's holding area (yellow zone). SW EE explained that patients in the yellow zone are seen as if they are on the inpatient unit.

A phone interview with the Registered Nurse (RN) CC was conducted on 12/28/21 at 4:25 p.m., in the facility conference room. RN CC stated that she was an agency nurse who worked in the emergency department (ED). She said that she recalled P#1. She continued to say that P#1 was seen in the ED due to orthostatic hypotension (decrease in blood pressure when assuming an upright position). She recalled that he was recently diagnosed with dementia and was alert and oriented x2 (person and place) and sometimes x3 (person, place, time). RN CC continued saying that P#1 was agitated throughout the night, and on multiple occasions, he tried to leave his room and stated that he wanted to go home. RN CC said that she contacted his provider to get some medication to help him rest, and P#1 slept a good portion of the night after receiving the medication. She stated that P#1 had a few incontinent accidents during the night, and RN CC recalled cleaning P#1 up afterward. RN CC stated that she did not recall seeing any significant wounds when providing incontinent care. She explained that she provided care to P#1 while he was a patient in the ED and continued to do so once he was admitted to the facility. The facility did not have an inpatient bed available, so P#1 remained on a bed hold in the ED. RN CC explained that P#1 was moved to the Yellow Zone in the ED the following morning, and he received a different nurse once he was moved. RN CC continued to explain that the Yellow Zone was an area in the ED where patients waiting for a bed on an inpatient unit could be held until the inpatient bed became available. She further stated that an incident involving P#1 occurred the morning after his admission. RN CC said she was on her way to P#1's room for bedside shift report, and when she entered, she found P#1 on the floor. She stated that she assisted P#1 onto his bed and provided a neuro exam. She continued to say that P#1 had sustained a bruise to his left temple. She further said that P#1 was on a blood thinner and had a history of a stroke. RN CC stated that she notified the charge nurse, house supervisor, and P#1's provider. P#1 was oriented but seemed lethargic. A Computerized Tomography (CT) scan (x-ray images of bones, blood vessels, and soft tissues) was ordered. RN CC stated that P#1 had fall precautions (bed rails up, yellow non-slip socks, call light within reach) in place prior to P#1's fall. She further stated that she did not recall if P#1 had a Fall Risk Assessment completed. She explained that the Fall Risk Assessment was typically done during triage. RN CC said that she had completed the Fall Risk Assessments on occasion after a patient had been triaged and would specify the assessment in her nursing notes. RN CC said that she was unaware that she needed to document P#1's fall on the Post Fall Documentation Flowsheet. RN CC said P#1 did not have a safety sitter. She stated that she tried to provide one-on-one observation for P#1. She explained that she propped her computer by P#1's doorway and watched P#1 while caring for her other patients. RN CC explained that if a patient were admitted to the facility and was on a bed hold in the ED, she would continue to chart using the ED charting system. She continued to say that she did not have a lot of knowledge about the required inpatient documentation that needed to be completed. RN CC stated that the ED performed their nursing assessments differently than the inpatient units.

An interview with Wound Care Ostomy Nurse (WCON) KK was conducted on 12/28/21 at 4:50 p.m. in the facility conference room. WCON KK explained that she had been a WCON for two and half years. WCON KK explained that when a wound care order was initiated, it would populate into the new consult list that she printed daily. She further stated that she would see a patient with a new consult within 72 hours and sometimes the following day. WCON KK said that new consults and wound care were not provided on the weekends. She explained that she would assess the patient's wounds, clean the wound bed, and take photos of the wounds when she met with a patient. Then, she would decide on the best treatment, and if she had everything at the bedside to treat the wounds, she would perform it herself. If a medication were not available and needed to be ordered from the pharmacy, she would place specific instructions into the patient's medical record. Then, the patient's bedside nurse would provide the care and treatment. WCON KK said that newly hired nurses shadowed her, and she offered an overview of wound care. She explained that each unit had a Wound Care Treatment Resource Book that contained the Wound Care policies and Wound Care Treatment Guidelines with pictures to assist the bedside nurse. WCON KK stated she was unaware if the ED had a copy of the Wound Care Treatment Resource Guide. WCON KK further stated that she expected that bedside nurses could provide standard wound care. WCON KK said that P#1's name sounded familiar but could not recall any details about P#1








A telephone interview with Registered Nurse (RN) GG took place on 12/28/21 at 5:20 p.m. RN GG explained that he works in the emergency department at the facility and could not recall anything about P#1. When asked about fall risk assessment, RN GG said that assessing a patient at the facility's ED for falls typically depends on how sick was the patient. RN GG explained that in a perfect world they were supposed to do a fall risk assessment but if the patient is unstable they needed to do blood works and stabilize the patient. RN GG explained that fall risk assessment is part of triage assessment but this is not what they can complete, because they are trying to help nurses that are overwhelmed. RN GG said that the emergency rooms are chaotic and ER patients are not stable. RN GG further explained that he would stabilize the patient's blood pressure and prioritize which patient is medically unstable over assessing for fall risks. RN GG said fall risk assessment will be done on the inpatient admission. RN GG said If a patient is going to be admitted at the facility a lot of stuff doesn't get done at the ED because they are done upstairs (inpatient unit). RN GG explained that since the beginning of COVID the yellow zone had been used as a patient hold, he further explained that since the covid surge it is not uncommon to have emergency and inpatient mix together at the ED. RN GG explained that he could not remember any training on how to care for inpatient admits present at the ED. RN GG said that he could not remember how much of a fall risk was P#1, he further said that if the EMS said P#1 was a fall risk maybe they made a mistake or probably P#1 was no longer a fall risk once he got to the hospital. When asked if he could consider a fall risk assessment for a patient on chemical restraint, RN GG said that if the patient was on restraints that means probably the patient was combative and it was not possible to assess the patient for falls. RN GG said that since the vaccine mandate the facility had lost a lot of staff and staffing had become a problem.

An interview with the Director of Patient Safety and Quality (DPS) MM took place on 12/29/21 at 10:47 a.m. DPS MM explained that she had been working at the facility for 13 months and her job roles included patient safety and quality oversight. DPS MM explained that the hospital had a fall improvement committee and their responsibility was to trend fall data, looking for trends and measures to reduce falls. DPS MM further explained that before the pandemic the committee intended to meet on monthly basis but unfortunately since July 2021 the facility had not done any trending on falls. DPS MM said she was not aware of any quality improvement involving actively tracking pressure injuries within the facility. DPS MM explained that safety sitters are not required to complete any documentation, she further explained that if the sit

Based on review of medical record, policies and procedures ,staff interviews, observations, incident reports,quality and fall committee meeting minutes, it was determined the facility failed to provide appropriate nursing assessments to one of 4 sampled patients (P#1). Specifically, the facility failed to provide an initial nursing assessment including an assessment of all P#1's skin surfaces (head to toe), fall risk assessment on admission. The facility failed to meet the patient's (P#1) needs by not providing and implementing a fall plan of care, educating P#1 and/or P#1's family regarding fall risk and interventions, assessing and implementing fall prevention strategies to decrease the risk of patient falls prior to P#1 falling at the facility.

Findings:

A review of Patient (P), P#1 medical record revealed that P#1 presented to the facility's emergency department (ED) by EMS on 11/19/21 at 4:35 pm for orthostatic hypotension (low blood pressure when standing) due to decreased oral intake. P#1 had a past medical history of stroke (loss of blood flow to part of the brain), chronic kidney disease, arthritis (inflamed joints), and had recently developed dementia (loss of memory).

On 11/19/21 at 4:54 p.m., ED triage notes by RN GG revealed that the EMS was called by P#1's home health RN stating that P#1's blood pressure dropped when standing to 70/40 mmHg. RN GG noted P#1 with a new diagnosis of dementia and had recently stayed at rehab for ambulation. RN GG documented that per EMS P#1 was a fall risk.

On 11/19/21 at 6:50 p.m., P#1 ED's physical examination revealed that patient #1 was alert and disoriented.
A review of the admitting physician (MD AA) history and physical on 11/19/21 at 7.30 p.m. revealed that P#1 had a chronic sacral (bottom of the spine) ulcer (injuries to the skin and underlying tissue) present on admission. P#1 presented with low blood pressure and was reportedly not eating or drinking much. Further review of the history and physical note revealed that P#1 was recently discharged from a rehabilitation center after receiving physical therapy for frequent falls. P#1 was admitted on 11/19/21 at 9:04 p.m. to the facility for further evaluation and management of his low blood pressure and acute kidney injury.

P#1 medical record failed to reveal an initial nursing assessment including fall risk and skin assessment on admission to the facility.

On 11/20/21 at 12:10 a.m., RN CC documented that P#1 was agitated, confused, and attempted to get out of his bed twice. RN CC noted that P#1 was redirected and cleaned, P#1's door was open for 1:1 continuous monitoring, and RN CC notified the physician. MD AA ordered P#1 Haldol (antipsychotic) injection for agitation at 12:15 a.m. The order was administered by RN CC.

On 11/20/21 at 4:30 a.m., RN CC documented that P#1 attempted to get out of bed again and P#1 was able to be redirected back into bed.

On 11/20/21 at 7:53 a.m., RN CC noted that P#1 was found face down on the floor with a hematoma (collection of blood) on the left side of the forehead and blood noted on the floor. RN CC notified the physician, charge RN, and house supervisor. MD LL reassessed P#1 after the fall. MD LL documented that P#1 had a 2cm laceration (cut) to his left forehead with surrounding hematoma. P#1 was noted to be drowsy, oriented to self and place. MD LL ordered head and spine CT (computed tomography, diagnostic test to review changes inside the body), chest and pelvis X-ray, and a sitter for P#1 on 11/20/21 at 7:42 a.m.

The facility failed to provide documentation supporting a sitter was documented at P#1 ' s bedside.

A review of the head and spine CT report performed on 11/20/21 at 8:00 a.m. revealed a hematoma to the left side of the forehead, there was no intracranial (within the skull) hemorrhage or fractures (breaks in the bone) of the cervical spine.

P#1 ' s medical record failed to reveal an order for wound care and dietitian consultation.

A review of the facility's flowsheet assessment included the following:
On 11/20/21 at 8:45 a.m., P#1 was noted to be alert. At 9:00 a.m. P#1's ED fall risk assessment was completed. A review of the facility's flowsheet failed to reveal a fall risk assessment prior to P#1 falling. P#1 fell at the facility and was found face down on the floor at 7:40 a.m.

On 11/21/21 at 7:35 a.m., RN OO documented that P#1 was alert, oriented to person and place. RN OO noted P#1 with impaired vision, limited movement of the right and left lower extremity (legs). P#1 fall risk score was 22 (>10 high risks for falls), Braden scale ( scale for bed sore risk) score was 17(15 to 18 is mild risk, 12-14 is moderate risk, 10-12 is high risk, and 9 and above is very high risk). P#1 was noted to have forehead bruises. Further review failed to reveal pressure injury locations and interventions at this time.

On 11/22/21 at 8:00 a.m., facility flowsheet revealed that P#1 was alert, oriented to place, time and person. P#1 had impaired vision, limited movement of the right and left lower extremities. P#1's Braden scale score was 17, P#1 had forehead bruises. At 2:37 pm P#1 was noted to be oriented to person. Further review of the flowsheet failed to reveal a pressure injury at this time.

On 11/23/21 at 8:00 a.m., the facility's flowsheet revealed that P#1 was alert, oriented to person, place, and time. P#1's Braden score was 13. P#1 was noted to have limited movement of all limbs. P#1 had urinary incontinence. P#1's sacrum pressure injury was noted and dressed.

A review of the facility's care plan revealed that P#1's safety/fall plan started on 11/21/21. At 7:35 a.m. RN OO documented that P#1 verbalized understanding of falls education, precautions, prevention at home and while at the hospital.

A review of the facility's care coordination initial assessment revealed that P#1's discharge planning began on 11/20/21. At 12:08 PM SW EE documented that P#1 was anticipated to be discharged back home with home health service when medically ready. SW EE noted that P#1 had bowel and urinary incontinence and needed moderate assistance.

On 11/22/21 at 5:48 p.m., SW EE noted that she spoke with P#1's spouse and P#1's spouse declined hospice. P#1's spouse asked that P#1 return home with home health.
A review of the discharged information revealed that P#1 was discharged from the facility on 11/23/21 at 7:21 p.m. to a skilled nursing facility. P#1 discharge instruction, medications, follow-up information were completed. P#1 was noted to be stable on discharge.

A review of the Wound Care Consult request log dated 11/19/21 at 10:33 a.m. to 11/23/21 at 9:04 a.m. revealed that P#1 was on the Wound Care schedule on 11/22/21. Additionally, P#1's name was noted on the Wound Care schedule dated 11/23/21 but was not assessed due to the patient's discharge from the facility.

A review of the facility's policy entitled "Fall Risk Assessment and Prevention," Policy #PS-45, last revised 1/2018, revealed that the facility's policy was to assess a patient for fall risk and implement fall prevention strategies to decrease the risk of patient falls.
The following procedure would be as follows:

1. A Registered Nurse (RN) would assess the patient for any fall risk on admission. The patient would be reassessed for a fall risk when a change in caregiver or patient condition may affect the fall risk.
2. An RN would implement a Fall Plan of Care for a patient at risk (score of 10 or greater).
Additional fall precautions measures would be implemented as clinically indicated by risk factors that were assessed. The patient would remain on fall precautions and fall prevention interventions until the fall risk score was nine or less on two consecutive assessments.
Bed alarms would remain on for patients with a score of 10 or greater. If the patient was out of bed for any reason (i.e., diagnostic test, up in a chair, etc.), the alarm could be disengaged and then reactivated when the patient returned to the bed.
3. During hand-off communication and unit-based "huddles, "healthcare team members would communicate the increased fall risk to other healthcare team members during hand-off communication and unit-based "huddles." The patient would be identified using yellow skid-proof socks, a yellow caution light or a yellow door sign, and a yellow armband.
4. The patient and the patient's family should receive education regarding fall risk and interventions. They should receive the patient/family education brochure on fall prevention in the purple admission packet. They should also receive ongoing education regarding interventions selected on the Fall Plan of Care.
5. An RN should document the fall risk assessment and progress towards the goals on the computerized documentation system and the designated computer downtime forms.
A change in the patient's condition that required modification of interventions should be documented in the Fall Plan of Care. In addition, patient/family education should be documented on the initiation of fall precautions and any changes in the fall prevention interventions.


A review of the facility's policy entitled "Assessment of the Patient," Policy #PE-05-01-, last revised 2/2017, revealed the following:
1. Assessment of the patient should be completed by a Licensed Health Care Professional.
a. The assessment should be completed upon entry into the system (within 12 hours of arrival to the inpatient unit).
b. Initial assessment should include the health history and physical assessment.
c. A Licensed Practical Nurse (LPN) could collect the nursing history, but the RN must review and co-sign.
2. Reassessment of the patient should be completed after non-invasive or invasive procedures, significant change in condition or diagnosis, and upon transfer to a different level of care or specialty unit.
3. Assessment of the patient should be completed for discharge planning needs.
a. The process should begin upon patient entry into the system.
b. Input from all disciplines involved in the patient's care was required.
c. The plan would be continually evaluated during the patient's hospitalization.


A review of the facility's policy entitled "Patient Rights and Responsibilities," Policy #R1-01-01, last revised 5/2013, revealed that any patient receiving medical, nursing, or healthcare of any kind or type within the facility would receive treatment in a respectful and safe environment.

A review of the facility's policy entitled "Patient Rights and Responsibilities," Policy #R1-01-01 Job Aid 1, last revised 5/2013 revealed that any patient receiving medical, nursing, or healthcare of any kind or type within the facility had the right to be free from the use of restraints and/or seclusion unless clinically necessary.


A review of the facility's policy entitled "Nursing Plan of Care," Policy #PS-51, last revised 8/2015, revealed that the Plan of Care (POC) would be individualized to meet the patient's needs based on data collected from the nursing assessment and would include involvement of the patient, family, and/or significant other. Care planning, treatment, and services would be collaborative and interdisciplinary.
The initiation of the POC would be as follows:

1. The patient would be assessed by a Registered Nurse (RN) on admission, and the POC selected would be based on an appropriate diagnosis. Co-morbidities and/or psychosocial issues would also be addressed.
2. The patient goals would be established.
3. Interventions would be documented and implemented to meet the individualized patient needs.
4. The patient would be reassessed at specified times based on the level of care or a significant change in the patient's condition.
5. The POC would be revised or reprioritized based on assessment or change in the patient's condition or diagnosis.
6. The established goals would be evaluated and documented.
7. The POC interventions would be continued, revised, or resolved to achieve the established goals.

A review of the facility's policy entitled, "Prevention of Pressure Injuries," Policy #PS-48, last revised 5/2018, revealed that:
1. A Registered Nurse (RN) would assess all skin surfaces on admission and every shift. Additionally, an RN would assess patient risk for developing pressure injury using the Braden Scale.
2. An RN would implement interventions for a patient with a Braden score greater than or equal to 18. An RN would also implement interventions for a patient with a Braden score of less than or equal to 17 or other high-risk indicators for impaired skin integrity.
3. An RN or Licensed Practical Nurse (LPN) would consult a dietician for patients with clinical indicators of high risk for impaired skin integrity.
An RN would document the Braden Score in the computerized documented system, the designated downtime forms, and/or the department-specific forms and flowsheets


A review of the facility's policy entitled "Treatment of Pressure Injuries," Policy #PS-49, last revised 1/2018, revealed the following:
1. A Registered Nurse (RN) should assess all skin surfaces on admission and every shift.
2. An RN should implement the wound care treatment guidelines by initiating the nurse-driven treatment protocol in the electronic medical record (EMR).
3. Consult the Wound Ostomy Continence (WOC) Nurse regarding altered skin integrity or additional assistance.
4. Consult a Dietician.
5. Document findings and treatment in the computerized documentation system or designated downtown forms.


A review of the facility's policy entitled "Maintenance of Skin Integrity," no date, revealed that the following items should be provided to patients to prevent skin breakdown:

1.Assess for a reddened area over bony prominences.
2.Minimize skin exposure to moisture from incontinence, perspiration, and wound drainage.
3.Instruct patient on cause and prevention of skin breakdown.
4.Keep skin clean, dry, and moisturized.
5.Use skin protective wipes or skin sealant under the tape with dressing change.
6.Limit the use of adhesive products on thin, fragile skin,
7.Maintain the head of the bed at the lowest degree of elevation.
8.Document any areas of redness that do not disappear within 30 minutes or any breaks in the skin.
9.Notify the Wound Care nurse when assistance was needed.

A review of the facility's policy entitled "Utilization of Safety Sitters," Policy #PS-72, last revised 6/2018, revealed that the policy's purpose was to ensure safe, quality care for patients receiving direct observation via "safety" sitters to prevent interruption of necessary medical therapies.
The procedure would be as follows:

1. Assess and identify the reason for behavior requiring intervention to reduce safety risks.
2. Initiate Safe Room Guidelines.
a. A sitter would be assigned to the patient.
3. Initiate Use of Safety Sitter Assessment Tool.
a. If possible, move the patient to a room closer to the nurse's station.
b. Ensure bed alarms were utilized.
c. Attempt diversion activities.
4. Complete Safety Sitter Request Form
a. Document process, verification of alternative diversion activities, family education, etc.
b. Retain form for audits.
5. Educate the family regarding the safety sitter role.
a. Include the patient's family/support system in the plan of care.
6. Notify the on-site staffing office of the approved need for a safety sitter.
7. Verify the sitter's presence and monitoring ratio by a note in the medical record.
a. Once the sitter arrived at the unit, the RN would document their presence and ratio of patient monitoring.
b. Appropriate forms were completed as assigned.
8. Provide hand-off to safety sitter assigned to the patient utilizing the Safety Communication Hand-Off Tool.
a. Unit staff would provide relief for safety sitters for breaks as needed.
b. Ensure continuity of observation to ensure safety and prevent falls, elopement, etc.
9. Reassess the need for a safety sitter every shift change.
The safety sitter utilization was a supplemental layer of safety and would not replace the care measures/observations by nursing, support, and/or the medical staff. In addition, the safety sitter needs were allocated based on the need and resources at the facility


An interview with Registered Nurse (RN) II was conducted on 12/28/21 at 10:15 a.m. in the facility conference room. RN II explained that she had been a nurse for 34 years and was currently working as a Nurse Professional Development Specialist. She continued to say that her role involved Acute Care education. RN II stated that an initial skin assessment should be completed on all patients on admission. The skin assessment would be completed by two nurses and documented on the flowsheet in the electronic medical record. She further stated that an electronic documentation timeline should be completed. RN II said that even though a patient was on a bed hold in the Yellow Zone area of the emergency department (ED), once the patient was admitted to the facility, the patient should receive all required admission assessments and completed documentation. RN II explained that all staff was trained through behavioral health to be safety sitters. She continued to say that the facility would seek specifically trained staff to care and sit with a patient, but any staff member could be a safety sitter. She further explained that a safety sitter would document on a paper document and be scanned into the electronic medical record (EMR). RN II explained that the inpatient units used the Hester Davis Scale for fall risk assessments, but the ED used a different fall risk assessment scale. She further explained that fall education that was completed on admission, bed alarm documentation, and activity daily living (ADL's) (bathing, oral care, urinary incontinence care, etc.) should be documented on the flowsheet in the EMR.

An interview with Patient Safety Coordinator (PSC) JJ took place on 12/28/21 at 11:00 a.m. PSC JJ explained that she had been working at the facility for twelve (12) years. She explained that her job responsibilities included reviewing safer events reported within the hospital and conducting root cause analysis. PSC JJ said that every patient who presented to the facility was supposed to get a fall risk assessment. PSC JJ said the ED fall risk assessment is separated into a green and yellow status, she explained that a green status meant low fall risk and a yellow status indicated a patient is a high fall risk. PSC JJ explained that patients with high fall risk are expected to have a fall risk armband, wear a yellow sock, bed in the low position, side rails up, call light in place, and their rooms closer to the nursing station. PSC JJ said that the initial nursing assessment including a fall risk and skin assessment was supposed to be completed within 24 hours of admission. PSC JJ acknowledged there was no initial nursing assessment done for P#1 after admission. PSC JJ explained that cleaning up patient are carried out as needed but is supposed to be completed at least every 24 hours.


An interview was conducted with Medical Doctor (MD) AA on 12/28/21 at 2:10 pm. MD AA acknowledged that he remembered admitting P#1. MD AA explained that P#1 came in with hypotension, chronic sacral ulcer, acute kidney injury, and was recently diagnosed with dementia. MD AA said he guessed P#1 fell the next morning. MD AA explained that the nurse said P#1 was trying to get out of the bed. MD AA said that for a patient with a chronic sacral ulcer present on admission he would put an order for a wound care consult and the nurses on admission will do a skin assessment for the patient. MD AA further explained that a full assessment including a fall risk and skin assessment is done for all patients upon admission. MD AA explained that the patient is in the facility's holding area (yellow zone) when there is a volume surge. MD AA further explained that patients kept at the yellow zone are close to the nursing station where nurses have direct visual. MD AA explained that if a patient is trying to get out of the bed he would order a sitter, he further explained that chemical restraint is necessary if the patient is combative, swinging, and has become a threat to themselves or others. MD AA explained that patients with dementia may be verbally redirected but if they are swinging, they need a dose of medicine to help. MD AA explained that a nutritional or dietitian consult order is initiated on admission to the floor for a patient with a chronic sacral ulcer, he further explained that nurses will do the full assessment and can put in the order for a wound and nutritional consult. MD AA said that the wound care nurse would get an alert once they are consulted and somehow, she was not available to care for P#1.

An interview with Registered Nurse (RN) FF was conducted on 12/28/21 at 2:35 p.m. in the facility conference room. RN FF explained that for the past 20 months, she had held the position of Director of Nursing for Emergency Services. She continued to say that she had been an RN for 20 years and most of her nursing background was in emergency medicine. RN FF explained that the emergency department (ED) held an eight-bed Yellow Zone pod. She continued to explain that with the surge of COVID-19, it had become necessary to keep patients admitted to the facility in the ED on a bed hold until an inpatient bed became available. The Yellow Zone would house those patients on an inpatient bed hold, and it was not unusual to have ED patients in the Yellow Zone simultaneously. RN FF stated that the preference was to have an inpatient nurse come to the ED Yellow Zone to provide care to those patients on an inpatient bed hold, but that was not always the case, and an ED nurse would be required to provide care for the inpatients currently on a bed hold in the ED. She continued to explain that at one point that there was a core group of nurses who had been cross-trained to care for the inpatients in the ED, but they were no longer available. RN FF further stated that not all ED nurses were trained on the procedures for new admissions, including skin assessments. But her expectations were that the ED nurses would have the basic knowledge to provide care for those inpatients. RN FF said that some patients received focus assessments and that assessing a patient and documentation would be based on a patient's condition and length of stay. She continued to say that the ED nurses were trained to apply dressings to pressure wounds and her expectation was that the ED nurses would document their actions in the patient's medical record. She stated that the ED assessed patients for falls, and they were given a green (low risk) or yellow (high risk). Green status included ensuring that the patient's call light was within reach and other items the patient may need. A yellow status included a yellow patient armband, call light within reach, yellow non-slip socks, bed rails up in a locked position, and hourly rounding on the patient. If a patient received a chemical restraint, RN FF stated that no additional fall prevention measures would be implemented. RN FF continued to say that activity daily living (ADL's) which included oral hygiene and bathing, could easily get missed for inpatients that were on a bed hold in the ED because it was not commonly performed in the ED. Her expectation was that patient hygiene would be addressed once a shift. RN FF further stated that she expected that ED staff keep a patient clean and dry if they were incontinent.

A follow-up interview was conducted with RN FF on 12/29/21 at 2:10 p.m. in the yellow zone of the Emergency Department. RN FF stated that the ED did not have the Wound Care Resource Guide; it was only inpatient. RN FF said that if a 1:1 safety sitter was ordered, there was never an incident that a sitter was not provided. She continued to say that the ED nurses at no time would be required to provide care for other patients while acting as a 1:1 safety sitter.

An interview was conducted with the Social worker (SW) EE on 12/28/21 at 3:43 pm. SW EE explained that could not recall the patient. SW EE explained that they typically conduct a discharge planning upon patient admission. SW EE said they would see the patient within 24 hours. SW EE said the care coordinator would speak with the patient or patient's family member and determine the discharge plan based on the patient medical condition. SW EE explained that discharged planning is carried out regardless of a patient being in the facility's holding area (yellow zone). SW EE explained that patients in the yellow zone are seen as if they are on the inpatient unit.

A phone interview with the Registered Nurse (RN) CC was conducted on 12/28/21 at 4:25 p.m., in the facility conference room. RN CC stated that she was an agency nurse who worked in the emergency department (ED). She said that she recalled P#1. She continued to say that P#1 was seen in the ED due to orthostatic hypotension (decrease in blood pressure when assuming an upright position). She recalled that he was recently diagnosed with dementia and was alert and oriented x2 (person and place) and sometimes x3 (person, place, time). RN CC continued saying that P#1 was agitated throughout the night, and on multiple occasions, he tried to leave his room and stated that he wanted to go home. RN CC said that she contacted his provider to get some medication to help him rest, and P#1 slept a good portion of the night after receiving the medication. She stated that P#1 had a few incontinent accidents during the night, and RN CC recalled cleaning P#1 up afterward. RN CC stated that she did not recall seeing any significant wounds when providing incontinent care. She explained that she provided care to P#1 while he was a patient in the ED and continued to do so once he was admitted to the facility. The facility did not have an inpatient bed available, so P#1 remained on a bed hold in the ED. RN CC explained that P#1 was moved to the Yellow Zone in the ED the following morning, and he received a different nurse once he was moved. RN CC continued to explain that the Yellow Zone was an area in the ED where patients waiting for a bed on an inpatient unit could be held until the inpatient bed became available. She further stated that an incident involving P#1 occurred the morning after his admission. RN CC said she was on her way to P#1's room for bedside shift report, and when she entered, she found P#1 on the floor. She stated that she assisted P#1 onto his bed and provided a neuro exam. She continued to say that P#1 had sustained a bruise to his left temple. She further said that P#1 was on a blood thinner and had a history of a stroke. RN CC stated that she notified the charge nurse, house supervisor, and P#1's provider. P#1 was oriented but seemed lethargic. A Computerized Tomography (CT) scan (x-ray images of bones, blood vessels, and soft tissues) was ordered. RN CC stated that P#1 had fall precautions (bed rails up, yellow non-slip socks, call light within reach) in place prior to P#1's fall. She further stated that she did not recall if P#1 had a Fall Risk Assessment completed. She explained that the Fall Risk Assessment was typically done during triage. RN CC said that she had completed the Fall Risk Assessments on occasion after a patient had been triaged and would specify the assessment in her nursing notes. RN CC said that she was unaware that she needed to document P#1's fall on the Post Fall Documentation Flowsheet. RN CC said P#1 did not have a safety sitter. She stated that she tried to provide one-on-one observation for P#1. She explained that she propped her computer by P#1's doorway and watched P#1 while caring for her other patients. RN CC explained that if a patient were admitted to the facility and was on a bed hold in the ED, she would continue to chart using the ED charting system. She continued to say that she did not have a lot of knowledge about the required inpatient documentation that needed to be completed. RN CC stated that the ED performed their nursing assessments differently than the inpatient units.

An interview with Wound Care Ostomy Nurse (WCON) KK was conducted on 12/28/21 at 4:50 p.m. in the facility conference room. WCON KK explained that she had been a WCON for two and half years. WCON KK explained that when a wound care order was initiated, it would populate into the new consult list that she printed daily. She further stated that she would see a patient with a new consult within 72 hours and sometimes the following day. WCON KK said that new consults and wound care were not provided on the weekends. She explained that she would assess the patient's wounds, clean the wound bed, and take photos of the wounds when she met with a patient. Then, she would decide on the best treatment, and if she had everything at the bedside to treat the wounds, she would perform it herself. If a medication were not available and needed to be ordered from the pharmacy, she would place specific instructions into the patient's medical record. Then, the patient's bedside nurse would provide the care and treatment. WCON KK said that newly hired nurses shadowed her, and she offered an overview of wound care. She explained that each unit had a Wound Care Treatment Resource Book that contained the Wound Care policies and Wound Care Treatment Guidelines with pictures to assist the bedside nurse. WCON KK stated she was unaware if the ED had a copy of the Wound Care Treatment Resource Guide. WCON KK further stated that she expected that bedside nurses could provide standard wound care. WCON KK said that P#1's name sounded familiar but could not recall any details about P#1








A telephone interview with Registered Nurse (RN) GG took place on 12/28/21 at 5:20 p.m. RN GG explained that he works in the emergency department at the facility and could not recall anything about P#1. When asked about fall risk assessment, RN GG said that assessing a patient at the facility's ED for falls typically depends on how sick was the patient. RN GG explained that in a perfect world they were supposed to do a fall risk assessment but if the patient is unstable they needed to do blood works and stabilize the patient. RN GG explained that fall risk assessment is part of triage assessment but this is not what they can complete, because they are trying to help nurses that are overwhelmed. RN GG said that the emergency rooms are chaotic and ER patients are not stable. RN GG further explained that he would stabilize the patient's blood pressure and prioritize which patient is medically unstable over assessing for fall risks. RN GG said fall risk assessment will be done on the inpatient admission. RN GG said If a patient is going to be admitted at the facility a lot of stuff doesn't get done at the ED because they are done upstairs (inpatient unit). RN GG explained that since the beginning of COVID the yellow zone had been used as a patient hold, he further explained that since the covid surge it is not uncommon to have emergency and inpatient mix together at the ED. RN GG explained that he could not remember any training on how to care for inpatient admits present at the ED. RN GG said that he could not remember how much of a fall risk was P#1, he further said that if the EMS said P#1 was a fall risk maybe they made a mistake or probably P#1 was no longer a fall risk once he got to the hospital. When asked if he could consider a fall risk assessment for a patient on chemical restraint, RN GG said that if the patient was on restraints that means probably the patient was combative and it was not possible to assess the patient for falls. RN GG said that since the vaccine mandate the facility had lost a lot of staff and staffing had become a problem.

An interview with the Director of Patient Safety and Quality (DPS) MM took place on 12/29/21 at 10:47 a.m. DPS MM explained that she had been working at the facility for 13 months and her job roles included patient safety and quality oversight. DPS MM explained that the hospital had a fall improvement committee and their responsibility was to trend fall data, looking for trends and measures to reduce falls. DPS MM further explained that before the pandemic the committee intended to meet on monthly basis but unfortunately since July 2021 the facility had not done any trending on falls. DPS MM said she was not aware of any quality improvement involving actively tracking pressure injuries within the facility. DPS MM explained that safety sitters are not required to complete any documentation, she further explained that if the sitter