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Based on interview and record review it was determined the facility's Governing Body failed to meet Conditions of Participation for Governing Body as evidence by:

The facility's Governing Body failed to ensure that the requirements of approved hospital policies were enforced.

1.) 3 of 3 patients were not place on fall precautions after being identified as a fall risk by nursing and physician assessments.

2.) The Initial Nursing Assessment document completed on 6/30/2019 for patient #2 revealed; the fall risk assessment was omitted. The facility policy indicates, fall risks will be identified at the time of admission.

3.) A review of the medical record for Patient #3 revealed, the Psychiatric Evaluation and History and Physical indicate the patient is a fall risk on the morning of 5/15/2019. The patient is sent to the Emergency Department to rule out traumatic brain injury on the afternoon of 5/15/2019 due to a fall. There is no evidence of a physician's order, indicating the patient is ever placed on fall precautions. Staff #2, Director of Risk Management, when asked if she was able to locate a physician order for fall precautions, she stated "no, I don't see one."

4.) A review of the medical record for Patient #4 revealed the Admission Assessment completed on 5/17/19, and the History and Physical completed on the morning of 5/18/19 indicate the patient is a Fall risk. The patient is not placed on Fall Precautions until the patient falls, and is sent the Emergency Room.

5.) The medical records for Patient #2 revealed the nurse did not obtain a physician's order for fall precautions within 2 hours after the patient fell on the adolescent unit. A fall was reported on 07/01/2019 at approximately 8:35 PM for Patient #2. A review of the Physician Orders revealed Fall precautions were not ordered until 7/2/2019 at 1:52 PM.

Cross Refer to Governing Body CFR 482.12 - 0063

The facility's Governing Body failed to ensure a doctor of medicine or osteopathy is on duty or on call at all times.

Patient #2 sustained a fall on 7/1/2019. It was later determined the fall resulted in a broken hip. There is no documentation or evidence the nurse attempted to contact the house supervisor, medical director, or administrator on call when she was unable to reach the on-call physician, as stated in the facilities hospital policy. Staff #3, Chief Nursing Officer, stated in part, "They (nursing) tried to call the doctor. She didn't get a call back..."

Cross Refer to Governing Body CFR 482.12 - 0067

These failed practices resulted in patients not being placed on fall precautions, subsequently patients fell requiring emergency services. The cumulative effect of systemic deficient practices resulted in noncompliance with the Condition of Participation of Governing Body.

Based on record review and interview it was determined the facility's Governing Body failed to ensure that the requirements of approved hospital policies were enforced.

Findings included:

The facility policy Gap Coverage stated in part,
"Policy: This process is to be utilized to resolve gaps in coverage when on-call physicians/Professional staff cannot respond. Examples of situations include but are not limited to:
1. Inability to reach a physician
2. Possible need for consultation
3. The patient is in need of immediate medical attention and the attending or consulting physician is unable to provide that treatment due to distance from hospital or unavailability.
Procedure:
1. Inability to reach Attending Physician or Designated Doctor On call within 30 minutes of attempt:
A. For patient already admitted, the nurse or assessor will notify the House Supervisor on duty. For patient not
yet admitted, the admission's department will notify the Medical Director and Administrator on-call.
B. The House Supervisor on duty will notify the Medical Director who will provide services until the physician
is contacted. The Administrator-on-Call and the Chief Executive Officer will be apprised.
2. Need for Consultation:
A. When the assessor reasonably believes that a consultation is needed, the assessor will suggest consultation
to the attending physician.
B. If no order for consultation is received:
1. If the patient is already admitted, the assessor will notify the appropriate House Supervisor who will assess
the situation and, upon confirming the need, will contact the attending physician and re-suggest the need for
consultation. If no order is received, the House Supervisor will contact the Medical Director who may obtain
consultation, at his/her discretion, or will contact the attending physician and facilitate the order for the
consultation
2. If the patient is in admissions', the assessor will notify the Medical Director who may obtain consultation, at
his/her discretion, or will contact the attending physician and facilitate the order for the consultation.
C. Note: The Medical Director may conclude that a consultation is not warranted.
...5. Documentation:
A. Documentation in the medical record will be included time entries stating efforts made to contact the attending or consulting physician's notification of nursing management or medical director."

Patient #2 sustained a fall, resulting in a fractured femur. There is no documentation or evidence the nurse attempted to contact the house supervisor, medical director, or administrator on call, when she was unable to reach the on-call physician per hospital policy. The fall was not reported to a medical provider until the following day, after Patient #2 had another fall.
Staff #3 Chief Nursing Officer stated in part, "They (nursing) tried to call the doctor. She didn't get a call back..."

The facility policy entitled Special Precautions stated in part, "Patient clinically identified as posing high risk for unsafe behavior shall be placed on defined precautions to increase awareness of risk to self or others in the areas identified and if indicated the level of staff observation may be increased.
... Procedure:
1. Patients are assessed for precautions needs at the time of admissions and throughout the hospitalization.
2. A special precaution shall be initiated for safety only and not as punishment or for convenience of staff.
3. A Registered Nurse or LVN may initiate precautions and observation levels but must obtain a physician order as soon as
possible.
4. A Registered Nurse or LVN may not lower a level of observation without a physician order.
5. Special precautions shall be evaluated every (8) hours by a registered nurse and every 24-hours by a physician.
6. ...
7. A physician must document need for continuation of precautions daily and renew order ...

The facility policy entitled Fall Assessment stated in part,
"Policy: All patients will be assessed for the potential to fall and will be placed on an appropriate prevention program upon admission in order to reduce the potential for falls and to limit injury from falling when falls occur.
Procedure:
...E. Frequency of Assessment:
a. A Fall Risk Assessment will be conducted within the initial Nursing Assessment
b. Any patient whose assessment indicates a HIGH risk for falls will be placed on Fall precautions and re- assessed every 12-hours until the risk level is LOW. Any HIGH RISK falls assessment finding will be
integrated into the Master Treatment Planning. Any patient on HIGH fall risk will have Fall Precautions in
place.
c. If a patient is assessed as LOW risk for falling, the patient will be screened for fall potential daily and a full re-assessment conducted any time there is any indication that a fall risk has occurred.
F. Physician order for fall precautions shall be re-evaluated every 24hrs
G. RN may place a patient on fall precautions based on clinical assessment and obtain a physician order within 2 hours..."

The Initial Nursing Assessment document completed on 6/30/2019 for patient #2 revealed, the fall risk assessment was omitted.

A review of the medical record for Patient #3 revealed, the Psychiatric Evaluation and History and Physical indicate the patient is a fall risk on the morning of 5/15/2019. The patient is sent to the Emergency Department to rule out traumatic brain injury on the afternoon of 5/15/2019 due to a fall. There is no evidence of a physician's order, indicating the patient is ever placed on fall precautions. Staff #2, Director of Risk Management, when asked if she was able to locate a physician order for fall precautions, she stated "no, I don't see one."

A review of the medical record for Patient #4 revealed the Admission Assessment completed on 5/17/19, and the History and Physical completed on the morning of 5/18/19 indicate the patient was a Fall risk. The patient is not placed on Fall Precautions until after a fall, and is subsequently sent the Emergency Room.

The medical records for Patient #2 revealed the nurse did not obtain a physician's order for fall precautions within 2 hours after the patient fell on the adolescent unit. A fall was reported on 07/01/2019 at approximated 8:35 PM for Patient #2. A review of the Physician Orders revealed Fall precautions were not order until 7/2/2019 at 1:52 PM.

Based on record review and interview it was determined the facility's Governing Body failed to ensure that the requirements of approved hospital policies were enforced.

Findings included:

The facility policy Gap Coverage stated in part,
"Policy: This process is to be utilized to resolve gaps in coverage when on-call physicians/Professional staff cannot respond. Examples of situations include but are not limited to:
1. Inability to reach a physician
2. Possible need for consultation
3. The patient is in need of immediate medical attention and the attending or consulting physician is unable to provide that treatment due to distance from hospital or unavailability.
Procedure:
1. Inability to reach Attending Physician or Designated Doctor On call within 30 minutes of attempt:
A. For patient already admitted, the nurse or assessor will notify the House Supervisor on duty. For patient not yet admitted, the admission's department will notify the Medical Director and Administrator on-call.
B. The House Supervisor on duty will notify the Medical Director who will provide services until the physician is contacted. The Administrator-on-Call and the Chief Executive Officer will be apprised.
2. Need for Consultation:
A. When the assessor reasonably believes that a consultation is needed, the assessor will suggest consultation to the attending physician.
B. If no order for consultation is received:
1. If the patient is already admitted, the assessor will notify the appropriate House Supervisor who will assess the situation and, upon confirming the need, will contact the attending physician and re-suggest the need for consultation. If no order is received, the House Supervisor will contact the Medical Director who may obtain consultation, at his/her discretion, or will contact the attending physician and facilitate the order for the consultation
2. If the patient is in admissions', the assessor will notify the Medical Director who may obtain consultation, at his/her discretion, or will contact the attending physician and facilitate the order for the consultation.
C. Note: The Medical Director may conclude that a consultation is not warranted.
...5. Documentation:
A. Documentation in the medical record will be included time entries stating efforts made to contact the attending or consulting physician's notification of nursing management or medical director."

Patient #2 sustained a fall, resulting in a fractured femur. There is no documentation or evidence the nurse attempted to contact the house supervisor, medical director, or administrator on call, when she was unable to reach the on-call physician per hospital policy. The fall was not reported to a medical provider until the following day, after Patient #2 had another fall.
Staff #3 Chief Nursing Officer stated in part, "They (nursing) tried to call the doctor. She didn't get a call back..."

Based on record review and interview, it was determined the facility failed to ensure care in a safe setting by identifying patients in need of fall precautions.

Findings included:

A review of the facility policy Rights of Voluntary Patients Seeking Discharge states in part:
"Basic Right for All Patients ... 3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity."

The facility policy entitled Special Precautions stated in part, "Patient clinically identified as posing high risk for unsafe behavior shall be placed on defined precautions to increase awareness of risk to self or others in the areas identified and if indicated the level of staff observation may be increased.
... Procedure:
1. Patients are assessed for precautions needs at the time of admissions and throughout the hospitalization.
2. A special precaution shall be initiated for safety only and not as punishment or for convenience of staff.
3. A Registered Nurse or LVN may initiate precautions and observation levels but must obtain a physician order as soon as
possible.
4. A Registered Nurse or LVN may not lower a level of observation without a physician order.
5. Special precautions shall be evaluated every (8) hours by a registered nurse and every 24-hours by a physician.
6. ...
7. A physician must document need for continuation of precautions daily and renew order ...

The facility policy entitled Fall Assessment stated in part,
"Policy: All patients will be assessed for the potential to fall and will be placed on an appropriate prevention program upon admission in order to reduce the potential for falls and to limit injury from falling when falls occur.
Procedure:
...E. Frequency of Assessment:
a. A Fall Risk Assessment will be conducted within the initial Nursing Assessment
b. Any patient whose assessment indicates a HIGH risk for falls will be placed on Fall precautions and re-assessed every 12-hours until the risk level is LOW. Any HIGH RISK falls assessment finding will be integrated into the Master Treatment Planning. Any patient on HIGH fall risk will have Fall Precautions in place.
c. If a patient is assessed as LOW risk for falling, the patient will be screened for fall potential daily and a full re-assessment conducted any time there is any indication that a fall risk has occurred.
F. Physician order for fall precautions shall be re-evaluated every 24hrs
G. RN may place a patient on fall precautions based on clinical assessment and obtain a physician order within 2 hours..."

The Initial Nursing Assessment document completed on 6/30/2019 for Patient #2 revealed, the fall risk assessment was omitted. Additionally, the medical records for Patient #2 revealed the nurse did not obtain a physician's order for fall precautions within 2 hours after the patient fell on the adolescent unit. A fall was reported on 07/01/2019 at approximated 8:35 pm for Patient #2. A review of the Physician Orders revealed Fall precautions were not order until 7/2/2019 at 1:52 pm.