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Based on record review and interview the Governing Body failed to ensure:

I. a policy was implemented that required formal consultation to be conducted with themselves or their designee and the Chief Medical Officer (or staff responsible for the organization and conduct of the medical staff) that occurred at a minimum biannually on topics that included, but were not limited to: scope and complexity of hospital services, patient population served, and identified issues involving patient safety and quality that required participation and input of the Medical Staff. (Refer to Tag A-0053).

II. The Quality Assurance Performance Improvement committee and Medical Staff were responsible and accountable for conducting an investigation and performance of a thorough analysis of adverse patient events to determine the cause of the event and implement actions to minimize or prevent re-occurrence. (Refer to Tag A-0286).

These failed practices had the likelihood for:

I. issues that required Medical Staff input to go unrecognized and unpursued, and result in missed quality opportunities to improve patient health and safety outcomes.

II. patient safety and quality of care issues to go unrecognized and unpursued by the Governing Body and result in missed opportunities for improvements in health outcomes for patients admitted to the hospital.

Based on record review and interview, the Governing Body failed to ensure:

I. a policy was implemented that required formal consultation to be conducted with themselves or their designee and the Chief Medical Officer (or staff responsible for the organization and conduct of the medical staff) that occurred at a minimum biannually on topics that included, but were not limited to: scope and complexity of hospital services, patient population served, and identified issues involving patient safety and quality that required participation and input of the Medical Staff.

II. consultative sessions were conducted between the COO and the Chief Medical Officer per policy. COO stated he/she and the Chief Medical Officer met frequently on an informal basis but had no formal consultations on a scheduled basis and there was documentation maintained to identify topics discussed.

These failed practices had the potential for issues that required Medical Staff input to go unrecognized and unpursued, and result in missed quality opportunities to improve patient health and safety outcomes.

Findings:

I. Policy

On 08/14/18 at 10:40 am, surveyors requested a policy that designated the requirements of formal consultations between the Governing Body (Board) and the Chief Medical Officer, the topics to include, but not limited to: scope and complexity of hospital services, patient population serviced, and identified issues involving patient safety and quality of care that required participation and input of the Medical Staff, and none was provided.

Review of hospital policy titled "Governing Board By-Laws, dated 09/12/17" showed each operating unit should meet with the Governing Body (Board) annually for general inspection, special presentations and consultations. The meeting should include the Health Administrator, Director of Nursing, Clinical Director, Administrative Officer and other appropriate staff from the operating unit. Members of the Governing Board included the Chief Medical Officer (Vice Chairperson) and the COO. The By-Laws did include formal consultative sessions between the Governing Body (Board) (or designee) and the Director of the Medical Staff, at minimum, biannually.

Review of hospital document titled "Bylaws of Medical Staff, dated 07/06/11" showed the duties and responsibilities of the Chief Medical Officer but did not include formal consultative sessions with the Governing Body (Board), at minimum, biannually.

On 08/20/18 at 3:41 pm, Staff A stated he/she had met frequently on an informal basis but there were no scheduled meetings or documentation of those meetings to identify topics discussed.

II. Consultative Sessions

Review of documents titled, "Minutes of the Governing Board Meeting" for 01/30/18 to 07/24/18 showed no documentation regarding formal consultative sessions between the Board (or designee) and the Chief Medical Officer regarding scope and complexity of hospital services, patient population serviced, and identified issues involving patient safety and quality of care that required participation and input of the Medical Staff. The minutes did show the COO was a member.

On 08/20/18 at 3:41 pm, Staff A (COO) stated the Chief Medical Officer met informally frequently in his/her office, regarding quality of care matters. The surveyors requested documentation of these informal meetings, none was provided.

Based on record review, interviews and observations, the hospital failed to:

I. provide a safe environment for suicidal/homicidal, abusive, aggressive, and/or combative patients admitted to the geri-psych unit as evidenced by:

a. Staff not maintaining line of sight (LOS) observation for one (Patient #4) of one patient with LOS orders and suicidal ideations. (Refer to Tag A-0144)

b. Four (Patient #2, 3, 14, 15, and 16) of 10 patients with suicidal and/or homicidal ideations, physical abusive, aggressive or combative were assessed by Medical Staff prior to placement with a roommate. (Refer to Tag A-0144)

These failed practices posed an Immediate Jeopardy to the Geri-psych patients' health and safety and had the likelihood to result in the increased risk of self-harm for one (Patient #4) of one suicidal patient with LOS orders that was left unattended, and increased risk for injury for two (Patient #20 and 21) of two patients placed in the same room with patients who had suicidal/homicidal ideations, physically abusive, aggressive and/or combative behaviors without prior assessment by Medical Staff.

On 08/15/18 at 2:54 pm, the COO and members of the hospital leadership team were notified of the Immediate Jeopardy conditions identified on the Geri-Psych unit.

On 08/16/18 at 12:00 pm, the hospital submitted a written plan of removal including:

*Completion of a patient analysis on all current geriatric psychiatric patients by the Deputy Chief Medical Officer, Chief of Staff, medical hospitalist, and unit psychiatrist. Four (Patient #2, 3, 14, 15, and 16) patients who had suicidal and/or homicidal ideations, abusive, aggressive or combative behaviors were co-mingled in two rooms.
*Hospital document titled "Inquiry/Assessment Form" was revised to include an assessment of patient for appropriate room assignment to be completed by the physician.
* Hospital policy titled "Admission Criteria" was revised to include the revisions to the Inquiry/Assessment form process.
*Patient observation level would be determined by the physician using patient clinical data at the time of patient admission.
*Physician would be responsible for documentation of room placement and level of observation (line of sight, 1 staff:1 patient [1:1]), within 24 hours of admission.
*All staff were to demonstrate competency on the levels of observation in the Geri-Psych unit by 08/20/18.

On 08/20/18 at 1:54 pm, the surveyors verified the hospital's plan of removal of the immediacy by:

A. Observation

*observed Patient #5 diagnosed with suicidal ideations and Patient #12 diagnosed with combative behaviors had been moved to individual rooms.

B. Interview with staff:

*interviewed staff to ensure education regarding levels of observation including line of sight and 1:1 was completed.
*interviewed staff regarding the process for determining if patients with suicidal and/or homicidal ideations, aggression, abusive or combative behaviors would not be placed with a roommate until assessment by a physician to determine safety.
*interviewed staff to ensure education was completed regarding observation of patients while in the common areas until lightweight furniture could be replaced.

C. Interview with leadership stated the following monitoring and reporting plan:

*Quality staff and/or House Supervisor to audit 100% of psychiatric patients who had been placed in medical beds for completion of the revised Inquiry/Assessment form criteria including assessment of patient's room assignment and level of observation. Audits to be completed within 24 hours of admission for the first month, followed by monthly audits until substantial compliance achieved.
* Chief Nursing Officer or designee to conduct observation rounding every four hours on all shifts to monitor staff compliance with level of observation orders.


II. ensure patients admitted to the Geri-psych unit with a documented fall risk were appropriately assessed for and placed on fall precautions.

This failed practice posed an Immediate Jeopardy to the Geri-psych patients' safety and had the liklihood to result in serious, potentially fatal outcomes from falls for 8(#4, 5, 12, 13, 14, 15, 16, 17) of the 10 patients with documented fall risk.

On 08/16/18 at 12:30 pm, OSDH surveyors identified an Immediate Jeopardy related to patient falls.

On 08/17/18 at 9:10 am, the COO and members of the hospital leadership team were notified of the Immediate Jeopardy conditions identified on the Geri-psych unit.

On 08/20/18 at 10:30 am, the hospital submitted a written plan of removal including:

· Identified nine patients with a Morse Fall Score > 45, placed all on fall precautions which included:
a. placed yellow non-skid socks and yellow onto all fall risk patients
b. educated all staff on fall assessment and documentation
c. approved and inserviced all staff on new fall prevention program policy
d. instituted hourly rounding to assess, document and update care plans
e. educated all staff on universal fall precaution interventions
f. placed 'Fall Precaution' signs on doors of fall risk patients
g. physician's order would be required for footwear other than non-skid socks

On 08/21/18 at 10:11am, surveyors verified the removal of the immediacy by:

A. Observation:
· observed nine (#4, 5, 12, 13, 14, 15, 16, 17, 21) of the nine patients with yellow armbands and yellow non-skid socks.
· observed all patient doors all 'Fall Precaution' sign

B. Interview with staff:
· interviewed staff to ensure their knowledge for determining appropriate fall risk score and implementation of univeral fall precaution strategies
· interviewed staff to ensure their knowledge of mitigating injuries associated with falls, including fall floor pads and hip protectors

C. Interview with leadership substantiated monitoring and reporting plan:
· staff competency of the Fall Prevention plan was demonstrated through completion of education and will be reviewed bi-annually
· nursing leadership will conduct observation rounding every six hours.
· all medical records of patients on high fall risk precautions will be audited and results reported to Quality and Governing Board.







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Based on record review, interviews and observations the hospital failed to:

I. Ensure staff maintained line of sight (LOS) observation for one (Patient #4) of one patient with orders for LOS and suicidal ideations. Surveyors observed assigned staff member at nurses' station while Patient #4 was unattended in the bathroom in his/her room down the hall.

II. Ensure four (Patient #2, 3, 14, 15, and 16) of 10 patients with suicidal and/or homicidal ideations, physical abusive, aggressive or combative were assessed by Medical Staff prior to placement with a roommate.

These failed practices posed an Immediate Jeopardy to the Geri-psych patients' health and safety and had the likelihood to result in the increased risk of self-harm for one (Patient #4) of one suicidal patient with LOS orders that was left unattended, and increased risk of injury for two (Patient #20 and 21) of two patients placed in the same room with patients who had suicidal/homicidal ideations, abusive, aggressive and/or combative behaviors without prior assessment by Medical Staff.

III. Ensure two (#5, 6) of 20 patients admitted to the Geri-Psych unit with a documented fall risk were appropriately assessed for and placed on fall precautions which may have prevented adverse outcomes, serious injury, and potential death from falls.

This failed practice led to 34 patient falls from 01/05/18 to 08/12/18 and one (#5) of twenty patient records reviewed with documented previous fall(s) and/or risk for fall, to fall which resulted in an adverse outcome, and one (#6) to sustain a serious injury after a fall and had the potential for all patients with documented fall risk to have adverse outcomes or sustain serious injury.

Findings:

Review of hospital document titled "Patient Rights & Responsibilities" showed patients should expect to receive "care in a safe setting ..."

Review of hospital document titled "Bylaws of Medical Staff, dated 07/06/11" showed medical staff were responsible for providing oversight of care ..."a uniform quality of safe patient care, treatment and services ..."

Review of hospital policy titled "Suicidal Patients, dated 03/20/18" showed precautions would be followed to ensure safe managements of patients who were or had the potential to become suicidal during their inpatient stay. Level of observation would be determined by the suicide lethality index (an assessment to determine the intent to commit suicide). The policy failed to define the levels of observation including line of sight (LOS) and 1:1 observation.

I. Line of Sight

On 08/15/18 at 9:00 am, surveyors observed Staff P's assigned to LOS observation for Patient #5 was standing at the nurses' station and Patient #5 was not within Staff P's line of sight. Patient #5 was in his/her bathroom with the door closed down the hall on the other side from the nurses' station where Staff P was standing.

On 08/15/18 at 9:05 am, Staff H stated Staff P's location while Patient #5 was in the bathroom was not the appropriate procedure for LOS observation.

II. Safety of Patient Placement with Roommate

Review of the electronic medical record (EMR) for four (Patient #2, 3, 14, 15, and 16) of 10 patients with suicidal and/or homicidal ideations, physically abusive, aggressive or combative behaviors showed the physician failed to assess the safety of placing the patient in a room with another patient.

On 08/14/18 at 10:50 am, Staff H stated determination of appropriateness for a roommate was not done prior to admission, it would be a team discussion after patient admission.


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III. Fall Risk Assessment

On 05/04/2018 at 2:00 am, Patient #6 fell and was discovered during RN rounding.There was no staff in the room at the time of the fall. Orders upon admission included fall precautions, fall protocol and LOS. The investigative report done by the facility showed no staff in the room at the time of the fall, nurses notes showed patient found on floor. The patient was transferred to another facility due to the CT scan not working at the facility. The CT revealed a subdural hematoma with a 20 centimeter laceration with a depth to the skull. On 05/04/18 at 4:30 am, the patient was transferred to a higher level of care and expired on 5/14/2018.

On 08/11/18, at 8:30 am, patient #5 fell. The physician had previously documented "continues to fall frequently". Documentation showed the patient was LOS and Fall Risk Protocol. On 08/12/18 the patient fell twice, once at 8:30 am, with no identified injuries, and again at 5:55 pm, at which time an x-ray revealed an acute fracture through the proximal portions of the 2nd metacarpal.

On 08/15/18 at 11:00 am, the unit had 10 patients. Eight (#4, 5, 12, 13, 14, 15, 16, and 17) of the 10 patients were on fall precautions. The patients were placed on fall precautions utilizing the current "Fall Prevention Policy", last revised 01/17/17. This policy showed "the purpose is to promote strategies to prevent in-patient falls and fall-related injuries." The policy further showed that "fall prevention strategies be implemented".

The following were measures/fall precautions (not all inclusive), to be implemented:
a. Patient fall alarms may be used when the patient is in bed or sitting in a chair.
b. Ambulatory patients should wear proper foot gear, nonskid shoes or well-fitting nonskid slippers.
c. An orange color identification band would be applied to all in-patients with a Morse Fall Score 25 or greater.
d. Fall Precaution Sign on patient door and in the room.

On 8/15/18 at 11:30 am, Staff L(charge nurse) stated alarms were not utilized for patients while in the chair. Staff L and Staff H (Unit Director) stated patients were to wear "yellow nonskid socks" if identified as a fall risk. Staff L also stated fall risk patients might wear shoes if deemed "appropriate" by nursing staff and further stated this was subjective. Both Staff L and H stated all fall risk patients "should" have been wearing yellow socks and yellow identification bands. They also both stated Fall Precaution signs were not placed on patient doors due to privacy concerns.

On 8/15 at 11:00 am, nine (#2, 4, 5, 12, 13, 14, 15, 16, 17) of the 10 patients were in the dining room, one (#9) of the 10 patients remained in their room with LOS maintained by staff.
a. zero of the eight patients had alarms in use.
b. one (#13) of the eight patients (with two documented falls during this stay), had no fall bracelet, no socks of any kind, and was wearing shoes commonly known as "flip flops" with no covering on the top of the foot. The toe and heel portions of the shoes were also open.
c. zero of the eight patients had orange colored identification bands.
d. there were no patient rooms with Fall Precaution Signs on patient door.

Based on record review and interview the hospital failed to establish an on-going quality improvement program that thoroughly investigated, analyzed the cause of medical errors and adverse patient events, implemented preventative actions and tracked performance to ensure the sustainability of improvements. QAPI Plan 2018 provided no evidence of performance improvement activities for adverse patient events. Incident Log for January 01/05/18 to 08/12/18 showed incidents including 34 falls, open pharmacy door, medication errors including two missing controlled medication events, inability to run lab tests due supply shortage, and delay in lab testing resulting in delay in patient care. . Review of QAPI minutes from 12/12/17 and 02/13/18 to 7/23/18, Medical Executive Committee (MEC) from 02/14/18 to 08/01/18 and Governing Board from 01/30/18 to 07/24/18 showed no evidence adverse events and medical errors were analyzed and evaluated. Staff A and D stated they were aware the minutes did not provide an accurate assessment of the discussions and recommendations that were discussed during Quality committee, MED and Governing Board meetings.

These failed practices had the likelihood to affect the safety and health outcomes of all patients receiving care in the hospital due to the hospital's failure to identify risks and quality improvement opportunities and implement action plans to improve patient outcomes.

Findings:

Review of hospital document titled "Continuous Quality Improvement Plan, dated 05/15/18" showed the hospital would implement, measure and analyze quality initiatives that would ensure ongoing quality care and identify problems and concerns. The Plan identified data would be collected from activities that included threats to patient safety such as adverse events. The Plan failed to show evidence of quality improvement activities focused on the reduction of adverse patient events and medical errors including goals and objectives for 2018.

Review of hospital documents titled "Incident Reports" from 01/05/18 to 08/12/18 showed there were the following adverse events:

*02/03/18 at 1:48 pm, lab test for troponin ordered at 1:48 pm, not resulted until 3:42 pm, and called to the ED at 3:49 pm. Troponin was elevated at 0.233 which resulted in a delay and change in patient care. Staff Q (ED physician) admitted patient (Patient #22) to hospital and moved to the floor. Staff Q called lab about test, error identified and lab personnel came and drew lab for test. Patient was subsequently transferred to another acute care facility for an acute myocardial infarction (heart attack). Outcome was documented as "no apparent injury". Investigative report focused on a single cause staff error. There was no evidence the incident was investigated and analyzed for additional causes or implementation of preventative actions to reduce the risk of recurrence in time critical cases.

*05/04/18 at 1:45 am, staff heard "a thud" and upon entering room found patient (Patient #6) on floor "with a spoon shaped laceration to head". House supervisor and physician notified and order received to transfer patient to ED for evaluation and treatment. Outcome was documented "death (error contributed to or resulted in death)". The investigation failed to analyze all causes that contributed to the fall including the patient was on LOS observation and was unattended at the time of the fall that resulted in serious injury and no physician assessment of the patient's musculoskeletal and neurological status.

*07/10/18 at 5:15 am, incident entered "fall while walking (unwitnessed)". Nursing staff heard "a thud", found patient (Patient #8) lying on front side with bleeding from the left side of the forehead. Pressure dressing applied and bleeding stopped. Physician and family notified. Outcome was documented as "minor injury/minor treatment with need for follow-up care". Investigative report failed to document a thorough investigation including but not limited to: medical record review to identify the times of the last 30 minute round and 15 minute safety check completed by staff to determine the time interval between the last visual observation and the fall. No evidence of interviews of staff involved in patient event. Report documented "patient could be placed on one to one, however low staffing", with no evidence of an effective action plan to prevent reoccurrence.

*08/12/18 at 8:30 am, incident entered "fall while walking (unwitnessed)", staff alerted by loud noise from patient's room. Patient (Patient #5) fell while trying to go to bathroom. Patient reported hitting his/her head. Bruising noted to left side of forehead. Physician notified, order for CT scan of head. Patient moved closer to nurses' station. CT results were negative. Outcome was documented as "minor injury/minor treatment with no need for follow-up care".

*08/12/18 at 4:37 pm, incident entered "fall while walking (unwitnessed)", staff alerted by loud noise from patient's room. Patient (Patient #5) fell while trying to go to bathroom. Patient moved closer to nurses' station. Physician notified, no new orders. Outcome was documented as "minor injury/minor treatment with no need for follow-up care".

Review of hospital document titled "Quality/Safety/Infection Control Sub-Committee" minutes from 12/12/17 and 02/13/18 to 7/23/18 showed minimal monitoring of data for quality indicators without evidence of discussion regarding analysis, evaluation and recommendations for improvement for medical errors and adverse patient events to prevent reoccurrence. Review of minutes from 07/23/18 showed no evidence of discussions of the adverse patient event involving Patient #6 following the completion of the investigation on 05/23/18 to analyze root cause(s) of the event, implement preventative action plans and move forward to MEC and Governing Body for approval.

Review of hospital documents titled "Fall Prevention Committee' minutes from 5/16/18 to 07/20/18 showed revision of fall prevention policy, development of fall signage, environmental risk assessment, ensured adequate supply of yellow socks and wrist bands (high fall risk identification), and implementation of annual training plan for topics related to fall prevention for staff. Review of minutes from 07/20/18 showed discussion regarding "how to investigate and close" on the topic "occurrence events related to falls". Minutes failed to show discussion related to falls occurring on the geri-psych unit to determine the cause, and development of action plans for improvement.

Review of hospital document titled "Trending Fall Data, 01/01/18 to 07/26/18" showed falls mainly occurred on the geri-pysch unit at a rate of 69% for three main reasons: patients tripping on scrub pant legs that were too long, wheelchairs (tripping over legs or falling out of) and rolling chairs in hallways. Recommendations made from review of the data were to ensure patient's clothing did not create a risk for falls, wheelchairs were locked when not in use or stored away and replace rolling chairs with stationary chairs. Time of day was determined to be a factor contributing to falls that occurred between 8:00 pm and 8:00 am (night shift hours). Recommendations made included but not limited to: increased staff and use of sitters for confused, high risk patients.

Review of hospital documents titled "Medical Executive Committee" minutes from 02/14/18 to 08/01/18 and "Minutes of the Governing Board Meeting" for 01/30/18 to 07/24/18 showed no evidence of review, analysis, evaluation and recommendations for improvement for medical errors and adverse patient events to prevent reoccurrences. Review of the minutes showed no evidence of discussions of the adverse patient event involving Patient #6 following the completion of the investigation on 05/23/18 to analyze root cause(s) of events and discuss recommendations to prevent reoccurrences, improve patient safety and quality outcomes for patients.

On 08/20/18 at 2:33 pm, Staff A and Staff D stated quality indicator dashboards were discussed at Governing Board meetings but the minute taker had been cautioned about putting so much in the minutes, he/she may have been too cautious. Staff D stated the Governing Board was provided a report a performance report and a dashboard each month that the members go over during the meeting that includes adverse patient events. Staff D stated Patient #6 was discussed during the meeting on 06/19/18, he/she pulled the incident report up on the screen and discussed it with the members. Staff D stated the discussion and any recommendations were not reflected in the minutes.

On 08/20/18 at 3:41 pm, Staff N (physician) stated he/she could not remember any adverse patient events being discussed at MEC. Staff N stated he/she did remember the event involving Patient #6 and did not think it was discussed at MEC. Staff N stated it may have went to peer review. Staff N stated peer review findings may not be discussed at MEC.

On 08/20/18 at 2:54 pm, Staff F stated adverse events related to falls were not discussed in quality. Staff F stated these events would be discussed in falls committee and safety committee. Staff F stated safety committee would do a monthly report to the quality committee. Staff F stated safety committee did not discuss Patient #6 "in particular". Staff F stated after the event involving Patient #6 the fall committee was implemented and a fall prevention program initiated.

Based on record review and interview the hospital failed to ensure medical staff were accountable to the Governing Body for the care provided to two (Patient #5 and 6) of a total sample of 20 patient medical records through quality review and analysis of these adverse patient events. Patient #5 known to have an unsteady gait and throwing self to floor resulting in injury, had two unwitnessed falls within 12 hours while on LOS observation and sustained a fracture of the left hand. Patient #6 with known history of dementia and stroke, no musculoskeletal or neurological assessment noted on admission, had an unwitnessed fall in the bathroom while on LOS observation and sustained a subdural hematoma in the left temporal lobe with mass effect of the left cerebral hemisphere and minimal midline shift.

This failed practice resulted in serious harm for two (Patient #5 and 6) patients of a total sample of 20 patient medical records reviewed, and the likelihood to affect the safety and health outcomes for all patients receiving care in the Geri-Psych unit due to the Medical Staff's failure to discuss, review and analyze adverse patient events, identify action plans and opportunities for improvement and report to the Governing Body.


Findings:

Review of hospital document titled "Bylaws of Medical Staff, dated 07/06/11" showed medical staff were responsible for providing patient focused quality care ...oversight of care ..."a uniform quality of safe patient care, treatment and services ..." and accountable to the Governing Board.

Review of hospital document titled "Patient Rights & Responsibilities" showed patients should expect to receive "care in a safe setting ..."

Review of hospital documents titled "Medical Executive Committee" minutes from 02/14/18 to 08/01/18 showed no evidence of discussion, review, analysis or action plans developed for adverse patient events.

Review of documents titled, "Minutes of the Governing Board Meeting" for 01/30/18 to 07/24/18 showed a document titled "Quality Management Review Report" attached with no evidence of discussion regarding adverse patient events. Quality Management Review Report dated May 2018 attached to the Minutes of the Governing Board Meeting for 06/19/18 noted under "Occurrences: ...5 patient falls - one death (Patient #6); 2 no apparent injuries; 1 minor injury." There was no documentation under "Governing Board Recommendations" and the minutes did not reflect any discussion between the Medical Staff and the Governing Board regarding review of this adverse patient event that resulted in serious harm.

Patient #5 was a 54 year old patient admitted on 08/11/18 at 3:15 pm, to the Geri-psych unit secondary to progressive worsening dementia, behavioral difficulties and reports of throwing self on floor. Review of the medical record showed the following:
*Patient #5 sustained a right forehead laceration from an episode of throwing self on floor just prior to arrival while in an outlying emergency department. On admission the patient had orders for LOS observation.
*On 08/11/18 at 6:13 pm, Staff Q (attending physician) performed a physical examination and noted patient to be "very unsteady with a very unsteady gait", no focal motor or sensory deficits identified. Patient was noted to have a tremor. Staff Q noted plan was to continue "to further assess patient's gait due to very unsteady gait".
*A Morse Fall Risk Scale was performed on admission with a score of 40 (Low/Moderate Risk).
*On 08/12/18 at 8:30 am, Staff L (RN) documented a Morse Fall Scale score of 95 (High Fall Risk) secondary to an unwitnessed fall that occurred in the patient's room while ambulating.
*On 08/12/18 at 9:15 am, Staff Q (attending physician) documented "continues to fall repeatedly, new skin tear left lateral forearm, x-ray acute fracture proximal portions of the left hand second metacarpal. No documentation in the patient's EMR regarding changes to the patient's plan of care and treatment to reduce the risk of falls and potential injury.
*08/12/18 at 2:12 pm, Staff K (RN) documented patient had "an unplanned descent to the floor that morning", Staff Q was notified and medication changes were ordered. Staff K noted the patient stated "I just fall a lot". There was no documentation the patient had sustained an injury to his/her left hand.
*On 08/12/18 at 5:55 pm, Staff L (RN) documented a Morse Fall Scale with a score of 85 (High Fall Risk) and Post Fall Assessment for a fall that was unwitnessed and occurred in the patient's room while ambulating at 4:37 pm.
*On 08/13/18 11:27 am, no documentation by Staff Q of second fall that occurred on 08/12/18 at 5:55 pm.


Patient #6 was an 88 year old patient admitted on 05/02/18 to the Geri-psych unit secondary to history of dementia and stroke with decreasing cognitive abilities, and had been recently hallucinating and combative at nursing home. Review of the medical record showed the following:
*Orders for LOS observation were placed into the patient's EMR on 05/02/18 at 1:05 pm by Staff R (hospitalist) and reviewed by Staff L (RN).
*On 05/02/18 at 2:48 pm, Staff R (hospitalist) performed a medical evaluation on the patient. There was no evidence of a musculoskeletal or thorough neurological assessment. Neurologic exam noted patient as "alert".
*On 05/03/18 at 10:48 pm, Staff N (psychiatrist) evaluated patient and noted patient "had propensity for unsteady gait."
* On 05/04/18 at 3:39 am, Staff K (RN) noted the patient had been wandering from room to room knocking on patient doors and exit seeking. At 2:00 am during rounds patient had been noted in bed awake. At 2:05 am, patient was up to bathroom unassisted and slipped. Patient was alert and oriented to self. Pressure bandage was applied to patient's head and taken to the ED for treatment.
*ED documentation showed a laceration "that spanned from the middle of the forehead to the occiput" and measured 20 centimeters (cm) in length "reaching down to the skull". Wound was cleansed and sutured.
*On 05/04/18 at 4:30 am, a CT scan was performed and showed an acute left sided subdural hematoma in the lateral side of the temporal lobe. The hematoma measured up to 6 millimeters (mm) in thickness with concerns for an epidural hematoma superimposed. Local mass effect had occurred upon the left cerebral hemisphere with minimal midline shift of 1-2 mm. Frontal scalp contusion and laceration were noted.

On 08/20/18 at 2:33 pm, Staff D stated the Governing Board was provided a performance report and dashboard each month for members ro review during the meeting that included adverse patient events. Staff D stated Patient #6 was discussed during the meeting on 06/19/18, he/she pulled the incident report up on the screen and discussed it with the members. Staff D stated the discussion and any recommendations were not reflected in the minutes.

On 08/20/18 at 3:41 pm, Staff N (physician) stated he/she could not remember any adverse patient events being discussed at MEC. Staff N stated he/she did remember the event involving Patient #6 and did not think it was discussed at MEC. Staff N stated it may have went to peer review. Staff N stated peer review findings may not be discussed at MEC.

Based on record review and interview the hospital failed to ensure nursing staff performed and documented:

I. fall risk assessments at a minimum of each shift for six (Patient #2, 5, 7, 8, 12, and 23) of 23 medical records reviewed per hospital policy.

II. a post fall risk assessment for a sample of three (Patient #6, 7 and 23) of five patient fall reports per hospital policy.

These failed practices had:

I. the likelihood to result in an increased risk for adverse health outcomes for six (Patient #2, 5, 7, 8, 12 and 23) patients due to failure to perform and document a fall risk assessment to determine increased risk for fall related to medications, medical condition and treatment.

II. resulted in injury to one (Patient #6) patient and the likelihood for injuries to go unrecognized for two (Patient #7 and 23) patients leading to the increased risk of adverse health outcomes and inability for hospital to determine root causes due to post fall assessments not being performed and documented.

Findings:

Review of hospital policy titled "Fall Prevention, revised 01/17/17" showed fall assessments would be performed on admission ...once a shift ..."as the patient situation changed" ..."with administration of medications that could increase fall risk" ...post fall ..."if a fall occurred nursing should conduct and document a post-fall assessment."


I. Fall Risk Assessment Documented Each Shift

Review of the EMR for six (Patient #2, 5, 7, 8, 12 and 23) of 23 medical records showed the fall risk assessments were not documented for each shift during the patient's in-patient stay in the geri-psych unit.

On 08/17/18 at 2:07 pm, Staff L stated fall risk assessments were performed and documented in the patient's chart every shift and after the patient fell. Staff L stated the standardized fall risk assessment was the Morse Fall Score and it was done every shift.


II. Post Fall Assessment

Patient #6 was an 88 year old patient admitted on 05/02/18 to the Geri-psych unit secondary to a history of dementia and stroke with decreasing cognitive abilities, and had recently been hallucinating and combative at nursing home. Review of the medical record showed the following:
* On 05/04/18 at 3:39 am, Staff K (RN) noted the patient had been wandering from room to room knocking on patient doors and exit seeking. At 2:00 am, during rounds patient had been noted in bed awake. At 2:05 am, patient was up to bathroom unassisted and slipped.
*ED documentation showed a laceration "that spanned from the middle of the forehead to the occiput" and measured 20 cm in length "reaching down to the skull".
*On 05/04/18 at 4:30 am, a CT scan was performed and showed an acute left sided subdural hematomaFrontal scalp contusion and laceration were noted.
*There was no evidence the post fall assessment was documented in the patient's EMR.

Review of the EMR for two (Patient #7 and 23) of five patient falls reported showed the post fall assessments were not documented in the patient's medical record.

On 08/17/18 at 3:04 pm, Staff K stated following a patient fall we would ask the patient if they had any injuries, obtain vital signs, notify the physician, house supervisor, perform a physical assessment and a post-fall risk assessment.

Based on record review, interviews and observations, the hospital failed to provide a safe physical environment for suicidal/homicidal, physical abusive, aggressive, combative and/or self-harm patients on the Geri-psych unit as evidenced by:

I. 12 of 20 beds were medical beds with side rails that could result in injury and pose a ligature risk. The beds were moveable through an electrical or manual mechanism that had the potential for a patient to barricade themselves in the room and not be able to be extracted by staff in the event of an emergency. (Refer to Tag A-0701)

II. Eight (Patient #2, 3, 4, 9, 14, 15, 16, and 17) of 14 patients were placed in a medical bed who had a diagnosis or combination of diagnoses for suicidal and/or homicidal ideations, physically abusive, aggression or combativeness. (Refer to Tag A-0701)

III. Nightstands in patient rooms were moveable and had the potential for patients to barricade themselves in the room and not be able to be extracted by staff in the event of an emergency. (Refer to Tag A-0701)

IV. Day room and dining area risks included small metal frame lightweight chairs which could be used as a weapon by aggressive or combative patients resulting in patient or staff injury. (Refer to Tag A-0701)

These failed practices posed an Immediate Jeopardy to the Geri-psych patients' health and safety and had the likelihood to result in the increased risk of strangulation, crushing and other physical injuries, by the use of moveable medical beds with side rails that posed a ligature risk for eight (Patient #2, 3, 4, 9, 14, 15, 16, and 17) of 14 patients. An unsafe environment and risk to patient safety was created secondary to the staff's inability to extract patients from a barricaded room in the event of an emergency for the eight (Patient #2, 3, 4, 9, 14, 15, 16, and 17) geri-psych patients who were being monitored for suicidal/homicidal ideations, aggression, abusive and/or combative behavior.

On 08/15/18 at 2:54 pm, the COO and members of the hospital leadership team were notified of the Immediate Jeopardy conditions identified on the Geri-Psych unit.

On 08/16/18 at 12:00 pm, the hospital submitted a written plan of removal including:

*Completion of a patient analysis on all current geriatric psychiatric patients by the Deputy Chief Medical Officer, Chief of Staff, medical hospitalist, and unit psychiatrist. Two (Patient #5 and 13) of ten patients were identified to have a current need for a medical bed which the attending physician documented in the patient's EMR.
*Two (Patient #5 and 13) patients with medical beds were moved to the same room under the observation of a sitter while in their room to mitigate risk. The sitter would be instructed to document safety checks every 15 minutes in each patient's EMR.
*Ten medical beds were replaced with ligature resistant platform or sled beds, as well as one psych-safe medical bed. The psych-safe medical bed had been bolted to the floor.
*All bedside tables and night stands were immediately removed from the unit with the exception of one room. One night stand was bolted to the floor to accommodate the use of medical equipment such as a CPAP machine.
*Hospital document titled "Inquiry/Assessment Form" was revised to include an assessment of the patient's medical necessity for a medical bed to be completed by the physician.
* Hospital policy titled "Admission Criteria" was revised to include the revisions to the Inquiry/Assessment form process.
*Patient bed placement would be determined by the physician using patient clinical data at the time of patient admission.
*Physician would be responsible for documentation of the necessity for a medical bed within 24 hours of admission.
*Staff member would remain with patients in any common area with lightweight furniture until furniture can be replaced. Staff would document supervision of common areas on 15 minute safety checks.

On 08/20/18 at 1:54 pm, the surveyors verified the hospital's plan of removal of the immediacy by:

A. Observation

*observed two medical beds in one room with a night stand bolted to the floor which was not moveable by surveyor. Power cords were removed from the beds preventing the patient from moving the head and foot of bed without staff assistance. Review of two (Patient #5 and 13) patient medical records, each showed an order by the physician for LOS while in medical bed.
*observed one psych-safe medical bed bolted to the floor per manufacturer guidelines. Bed had an auto-lock out and required a key to turn features on. Key was located in the Director's office along with the bed's power cord only accessible by staff.
*observed all small metal frame chairs were removed from the day room.
*observed staff in dining room while patients were present.

B. Interview with staff:

*interviewed staff to ensure their knowledge for determining the medical necessity for a medical bed including the physician's order and a sitter while in bed.
*interviewed staff to ensure education was completed regarding observation of patients while in the common areas until lightweight furniture can be replaced.

C. Interview with leadership stated the following monitoring and reporting plan:

*Quality staff and/or House Supervisor to audit 100% of psychiatric patients who had been placed in medical bed for completion of the revised Inquiry/Assessment form criteria including assessment of patient's medical necessity for a medical bed, orders justifying the medical bed and sitter observation. Audits to be completed within 24 hours of admission for the first month, followed by monthly audits until substantial compliance achieved.


39452

Based on record review, interviews and observations, the hospital failed to provide a safe physical environment for suicidal/homicidal, physical abusive, aggressive, combative and/or self-harm patients on the Geri-psych unit as evidenced by:

I. 12 of 20 beds were medical beds with side rails that could result in injury and pose a ligature risk. The beds were moveable through an electrical or manual mechanism that had the potential for a patient to barricade themselves in the room and not be able to be extracted by staff in the event of an emergency.

II. Eight (Patient #2, 3, 4, 9, 14, 15, 16, and 17) of 14 patients were placed in a medical bed who had a diagnosis or combination of diagnoses for suicidal and/or homicidal ideations, physically abusive, aggression or combativeness.

III. Nightstands in patient rooms were moveable and had the potential for patients to barricade themselves in the room and not be able to be extracted by staff in the event of an emergency.

IV. Day room and dining area risks included small metal frame lightweight chairs which could be used as a weapon by aggressive or combative patients resulting in patient or staff injury.

These failed practices posed an Immediate Jeopardy to the Geri-psych patients' health and safety and had the likelihood to result in the increased risk of strangulation, crushing and other physical injuries, by the use of moveable medical beds with side rails that posed a ligature risk for eight (Patient #2, 3, 4, 9, 14, 15, 16, and 17) of 14 patients.

An unsafe environment and risk to patient safety was created secondary to the staff's inability to extract patients from a barricaded room in the event of an emergency for the eight (Patient #2, 3, 4, 9, 14, 15, 16, and 17) geri-psych patients who were being monitored for suicidal/homicidal ideations, aggression, abusive and/or combative behavior.

Findings:

On 08/14/18 at 10:43 am, the surveyors toured the Geri-psych unit and observed the following:
*12 of 20 beds on the unit were medical beds with side rails that could pose a ligature risk. The beds were moveable with a manual release to move the bed that could result in injury to self, other patients and/or staff, or be used to barricade self and others in room, preventing staff from entering in the case of an emergency.
*moveable night stands that could be used as a barricade preventing staff from entering the room in the case of an emergency.
*Common areas had small metal frame chairs that could be easily used as a weapon by aggressive or combative patients resulting in patient or staff injury.

On 08/14/18 at 10:50 am, Staff H stated he/she was aware the hospital beds presented a barricade risk. Staff H stated the charge nurse was responsible for deciding whether a patient was placed in a hospital bed not medical staff. Staff H stated patients were placed in medical beds who had "chronic medical issues such as respiratory issues". Staff H stated he/she did not know what medical conditions the 10 current patients had that warranted the use of the hospital beds who were suicidal/homicidal, physically abusive, aggressive and/or combative. Staff H stated there would not be an order or documentation in the patient's EMR by medical staff confirming the need for a hospital bed for these psychiatric patients. Staff H stated there was no assessment by medical staff to determine suitability and safety of the patient prior to placement in a hospital bed.