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.

1. Based on record reviews, administration
interviews, and policy review, the hospital
failed to implement the standard fall risk
interventions for patient #1 prior to a fall.
The hospital has a policy and procedure which
says the fall risk screening is to be performed
by nursing within 24 hours of patient's a admission.
This was noted in 1 of 10 record reviewed.

Failure of the hospital to implement Fall Risk
intervention procedures may place place patients
who are not screened at risk for falls.


1. On 11/12/2013 at 10:00 AM The investigator
interviewed the nurse manager of the
Behavioral Unit. The nurse manager reported
that patient #1 was admitted to the Behavioral
Unit for increased agitation on 09/20/2013.

2. During the interview the nurse manager
reported that the patient was ambulating
in the hallway without staff assistance.
The patient fell to the floor and hit the
right-side of her/his head on 09/27/2013
at 8:50 AM. The nurse notified the physician
about the patient's fall.

3. The nurse manager explained the Morse Fall Risk
Assessment Tool was used to assess patients
risk for falls. Nursing was to complete the
fall assessments with 24 hours of admission
and then once per shift. If the patient's
assessment scored over 50 the patient was in
the High Risk Category for falls and specific
fall risk precautions were implemented.
Review of the hospital's policy entitled,
"Fall Prevention for Adult Acute Care
Policy," supported the nurse manager's

4. On 11/12/2013 at 14:00 PM The investigator
reviewed the hospital's policy and procedure
for specific fall risks interventions for patient's
in the High Fall Risk category. Patient #1's
fall risk assessment placed him/her in the
high risk category. Review of patient #1's
medical record failed to provide evidence
on that the interventions were implemented.

5. On 11/13/2013 at 11:30 AM The investigator
interviewed the nursing manager asked,
What were the circumstances that
surrounding the patient's fall? The nurse manager
explained the patient was very frail and was
ambulating in the hallway without staff assistance
on 09/27/2013 at 8:50 AM.

6. On 11/13/2013 at 14:00 PM The investigator
interviewed the Physical Therapy Aide, Supervisor.
She/he explained that staff were to continuously
touch the patient when ambulating in the room
or hallway. This intervention was to be noted
on the patient's care plan. Review of the
patient's #1 care plan did not include
this intervention was to be done.

7. On 11/13/2013 at 13:45 PM
the investigator interviewed two
Registered Nurses who worked in the
Behavioral Unit. The two Registered
Nurses were asked to explain the
"Contact Guard Assist"procedure
described by the PT Aide Supervisor.
They explained they were not familiar
with the term and this procedure was
not found in the fall risk policy.

8. Nursing staff assessed that the patient was
in the High Risk Category for falls but failed to
implement safety procedure when patient
was ambulating independently in the hallway.

II. Based on record reviews, administration
interviews, and policy review, the hospital
failed to provide accurate neurological.
assessments to a patient that sustained a
head injury during fall. This was found
in 1 of 10 records reviewed
(Patient #1's record).

Failure to accurately perform neurological
assessments using evidence based practice
standards may result in patient changes in
neurological condition not being evaluated
in a timely manner neurology deficits.


1. On 11/13/2013 at 09:00 AM Per review of
the documentation on the nursing Progress Notes
dated 09/27/2013 at 8:50 AM, the documentation
revealed that the patient fell when ambulating and
hit the right side of his/her forehead on the floor.
The Registered Nurse informed the physician about
the patient's fall. A head CT scan was obtained
on that day and showed that the patient
had a blood clot with an Intracranial bleed.
Review of the physician's orders revealed
that nursing was to assess the patient's
neurological status every 4 hours.

2. On 11/13/2013 During the interview
with the Behavioral Unit nursing manager,
she/he reported that nursing uses the Glasgow
Coma Scale Tool to measure the patient's
neurological assessments. Nursing Service policies
and procedures stated that neurological assessments
were to be recorded in the Neurology Flow Sheet document.

3. Review of the nursing documentation noted on
the patient's Neurology Flow sheet revealed
that nursing assessed the patient's Glasgow
Coma Scale scores and the findings the
A. On 09/27/2013 at 9:15 AM the patient's initial
Glasgow Coma Scale score was 16.
A score of 16 meant the patient's neurology
assessments were within normal limits without
any neurological deficits.

B. On 09/27/2013 at 9:30 and 9:45 AM
the patient's second Glasgow Coma
Scale measured a total of 16 also unchanged.

C. Further review of other nursing documentation
that was entered on the patient's Neurology
Flow sheet dated 09/27/2013 timed at 9:15 AM,
9:30 AM and 9:45 AM indicated that the Glasgow
Coma Scale score was actually 12 was
a total of 16. A score of 12 indicates
neurological deficit.

4. On 11/13/2013 at 12:30 PM The investigator
interviewed the Patient Safety Director.
The Patient Safety Director reported that nursing
used the Glasgow Coma Scale Tool that
was referenced in the Trauma Nurse Critical
Care Book. The Patient Safety Director referred
to Chapter 6 that was entitled, "The Brain
and Cranial Trauma." This chapter identified in
Table 6-12 how to measure the patient's
neurology assessments. Review of the data
in Table 6-12 explained the following:
1. When patient's Glasgow Coma Scale scores
from 9 through 12. This score indicates the
patient received a moderate head injury
during a trauma incident.

2. The Patient Safety Director did not provide a
written hospital policy and procedure indicating
that the Glasgow Coma Scale reference was
approved by administration for nursing service
to assess patient's neurologcial assessments.

3. On 11/13/2013 at 2:00 PM, during an
interview with the Patient Safety Director,
the question was asked, "When did the
Behavioral nursing staff receive training to
use the Glasgow Coma Scale Tool?"
The Patient Safety Director contacted the
nursing educator who reported that the
nursing staff in the Behavioral Unit had not
received the training. The nursing manager
reported that staff often receive patients
with brain injury issues and that staff
need the training. The facility failed
to train nursing staff on the use of an
evidence-based neurological assessments tool.