The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on interview and record review, the hospital failed to provide a safe setting for 1 of 1 patients (Patient # 1). A) The nursing staff did not follow their "Post Falls Guidelines" policy, and/or B) Exercise good nursing judgement, to ensure safety interventions were initiated (providing a sitter) for an identified High Fall Risk patient.

Findings included:

A) The "Post Falls Guidelines" policy dated 11/09, noted the following:
-"Minor Injury defined as ...abrasion, bruise, minor laceration, skin tears and head trauma that is limited to soft tissue damage only."
-For "Minor Injury ...#6. Consider placement of sitter with patient, if appropriate. "
-"Major or High Risk Injury defined as ...fractures, head trauma that includes the cranial bones and the brain ...injuries which require medical or surgical intervention, increased hospital stay, or are disabling a degree that the patient will have any degree of permanent lessened function ...patient on anticoagulants ... "
-For "Major or High Risk Injury (Suspected Head/Neck Injury or Use of anticoagulant)...#5 Place sitter with patient. "

B) Patient #1's medical record reflected Patient # 1 experienced 2 falls while hospitalized :

Minor Injury Fall:
The nursing note dated 03/27/10 timed at 6:45 AM reflected, "patient's bed alarm was activated at 06:45 AM, RN went to patient's room and found patient lying on the floor with a cut above his right eye. Patient was assessed for further injuries and helped back to bed with assist X 2 (2-person assist). A rapid response was called and doctor (Personnel # 9) was paged..."

The nursing note dated 03/27/10 timed at the 8:00 AM, Nursing Day Shift assessment reflected, "cut above right eye from fall 03/27/10 ...injured during fall when trying to go to the bathroom ...on bedrest ...short term memory loss - out of bed by self." The Fall Risk Assessment score prior to this fall was 22, and re-assessment after the fall was 28.

The day shift nursing "Fall Risk Assessment," dated 03/27/10 timed at 8:00 AM reflected, after this fall, recorded "fall history: + 11 (2) falls during this visit ...cognition: patient not aware of physical limitations points: 28 ...high risk measures implemented: yes ...additional interventions may include: ...24 hours supervision/sitter, as needed ...High Fall risk comment: call light within reach, bed alarm on (comment did not include initiation of a sitter)."

Major or High Risk Injury Fall:
Patient # 1's Medication Administration Record reflected Patient # 1 received an anticoagulant, Plavix 75 mg. (milligrams) by mouth daily.

The nursing note dated 04/24/10 timed at 11:30 PM reflected, "alarms went off, when entered room nurse saw patient at foot of bed, who then slipped and fell . Patient landed on back and hit back of head. Laceration to left elbow. Occipital hematoma. Patient complained of headache. Rapid Response Team called immediately and doctor (Personnel # 10) paged. Patient placed on backboard and C-collar, and transported to CT for CT of Head and C-spine. Doctor (Personnel # 10) was notified of CT results which were negative."

The nursing note dated 04/24/10 timed at 11:30 PM, reflected under the "Post Falls Summary," that before Patient # 1's fall - sitter present: none..."

The nursing note for 04/25/10 at 8:00 AM reflected, "Received this AM but appears more confused for him, asking about moving something on the wall. Speech more garbled, non-coherent ...BP (blood pressure 133/79, P (pulse/heart rate)-94 which is higher for him. TC (telephone call) placed to doctor (Personnel # 10) to notify of change in patient. New orders received for repeat CT of Head." 8:45 AM, "Report of CT Scan Personnel # 10 to notify him. Also notified supervisor of possible transfer. " 9:42 AM, TC from Personnel # 10 who stated he spoke with accepting physician at another hospital, and that Patient # 1 will be transferred to them. " 10:00 AM, "Wife at bedside and ambulance arrived, discharged per stretcher with EMT's (emergency medical technicians) to receiving hospital."

The Radiology "CT of Head/Brain without contrast" reported four (4) separate areas of hemorrhage in Patient # 1's brain.

The physician's (Personnel # 10's) "Discharge Summary," included "Acute cranial bleed associated with a fall."

On 10/26/11 at 9:05 AM Personnel # 1 was interviewed. Personnel # 1 stated, "sitters can be requested by nursing staff through the Nursing Supervisor, and are used based on patient condition." Personnel # 1 confirmed a physician order is not required for a sitter, but is based on nursing judgment. Personnel # 1 verified the nursing staff had knowledge of Patient # 1's condition after a stroke, and his increased high fall risk after a reported minor injury fall during his first week in the hospital (PCU), but never requested a sitter for this patient with indications that an additional safety intervention was needed. Personnel # 1 confirmed nursing had not requested a sitter prior to Patient # 1's fall while he was on the Inpatient Rehabilitation unit, which resulted in a major head injury, while on an anticoagulant, and required his transfer to a higher level of care facility for a neurosurgeon.
Based on interview and record review, the hospital did not follow their grievance process. The hospital did not address a known grievance from a representative for 1 of 1 patients (Patient # 1). The hospital further failed to inform them of the time frames for review of the grievance, and/or provide them with a response.

Findings included:

On 10/26/11 at 4:20 PM Personnel # 4 was interviewed. Personnel # 4 confirmed Patient # 1's representative (wife) had not filed a complaint or grievance with the hospital. She said the first time the hospital had heard of the complaint was from a follow-up call routinely made by a contracted company (Company # 1) ,who contacted patients approximately 3 months after being discharged from the Inpatient Rehabilitation Unit. Personnel # 4 stated Personnel # 5 had reported to her, she had received a "Rapid Response Report," from Company # 1 on 07/20/10, with a complaint from Patient # 1's wife regarding her dissatisfaction with her husband's care while at the hospital. Personnel # 4 said she had advised Personnel # 5 the hospital did not need to follow-up on a complaint received from a satisfaction survey, and that she was following their hospital's "Complaint & Grievance" policy.

On 10/26/11 at 3:10 PM Personnel # 5 was interviewed. Personnel # 5 said she had reported the complaint she had received from Company # 1, and reported it to Personnel # 4, who had advised her that no follow-up was needed for this complaint from a satisfaction survey. Personnel # 5 provided a copy of the following report from Company # 1 which noted the following:

-"Information source (wife) stated, My husband had 3 falls at (hospital). Two injured his head, and he ended up with a subdural hematoma. He was doing very well and ready to come home within two days when this happened. The nurses at (hospital) were negligent and I am going to sue for medical negligence."

Personnel # 5 was asked if she had received any Rapid Response Reports in the past, and if so, what did she do to address them. Personnel #5 said she had received 3 prior reports from the company, and she had reported them to Risk Management, and she had also initiated the grievance process by calling the complainant. Personnel # 5 verified she had followed the advice from Risk Management, and had not initiated the grievance process for this serious complaint that met the definition of a "grievance."

In an interview at 4:20 PM on 10/26/11 with Personnel # 4, she agreed the complaint had been treated as a "complaint," not as a "grievance," and therefore, the hospital had not addressed the allegations made by the patient's representative (wife), according to the hospital's policy, including time frames for review and provision of a response to a "grievance."

The "Patient Complaint & Grievance Resolution Process," #9.115, dated 12/10, noted the following:
" Complaints that Would be considered a Grievance:
-Any request by a patient or a patient ' s representative to file a grievance.
-Any verbal or written complaints (including e-mails and faxes) from an inpatient, an outpatient, a released/discharged patient, or a patient's representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with CoPs (conditions of participation).
-Telephone calls received from a patient or patient's representative describing patient care issues.
Complaints that Would Not be considered a Grievance:
-Post hospital verbal communications, which would have been handled by staff present if staff was aware of the complaint. This includes patient satisfaction survey information. "