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 review of documentation, and interviews with facility staff, the facility failed to ensure that a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

The findings were:

The facility policy title, "Falls Precaution and Management," states, "Standard fall precaution will be implemented on all patients. All patient will be evaluated to identify 'standard risk' or 'high risk' for fall during the admission assessment process; at minimum of once every shift; following a change in medical condition and/or level of care; and post fall ... Standard Fall Risk Interventions: properly fitting non-skid footwear; bed placed in lowest position only 3 max side rails up; secure all locks on bed, stretcher, and wheelchair when in patient use; discuss importance of calling for assistance; patients will be rounded on to address the four P's - pain, positioning, potty, and placement of personal items ... High Fall Risk Interventions: Apply all standard fall risk precautions and the addition of the following: place a yellow arm band on patient; place yellow non-skid socks on patient; place fall risk signage on patient's door; apply bed alarm ..."

The facility policy titled, "Transportation of Patients Within the Facility," states, "Notification to Nursing Staff: Nurse must receive patient at bedside - do not leave patient without "hand off" occurring at bedside."

The following documents and select medical records of Patient #1 for dates of service 3/4/18 - 3/22/18 were reviewed:

1. The ED provider documentation on 3/4/18 revealed:
a. "Pt is 66 y/o female w/ hx of DM and ESRD who presents to ED via EMS s/p pt pulled out dialysis cath. EMS adds that pt fell at NH a few days ago. Pt has been recently altered and combative for several days. Pt last had full session of dialysis x2 days ago and is regularly scheduled for dialysis M/W/F. Pt from Baywood health rehab, hx limited due to pt condition. She states she feels like vomiting. Pt denies pain ... Unable to Obtain ROS Altered mental status ... Re-Evaluation & MDM: Unknown who primary renal team is after discussion with NH. Pt with anemia in setting of ESRD and recent bleeding from catheter. Pt consented for transfusion from child/NOK. Special procedure ordered but pt does not need immediate dialysis. She is altered. Ammonia pending. Son states pt has been altered recently but this is not very clear at this time. Will admit for further evaluation."

2.The nursing clinical note documentation on 3/22/18 revealed:
a. At 1509, a RN note stated, "Pt transferred to room 2083 in stable condition. Son informed of transfer. Pt alert and oriented on room air at time of transfer denies pain/discomfort all orders reviewed and verified ..."
b. At 2117, a RN note stated, "This nurse found patient on the floor with blood coming from the left side of her head. This nurse applied pressure and called for help. tech came into the room and also called for help. Once the patient was stabilized patient taken down for CT of the head, xray of left hip, shoulder, knee, hand and elbow. [physician] was notified at 1615. AOS notified at 1550 fall occurred at 1540. Patient has remained alert and oriented x4 since the fall. [physician] sutured the left ear. Patient is now resting in the bed."

3. The patient's Post Fall Huddle Form from 3/22/18 revealed:
a. "Patient a fall risk? Yes"
b. "History of falls prior to admission? Yes"
c. "What interventions were done for fall risk? Yellow Sox"
d. "Fall risk factors prior to fall: Impaired mobility, Impaired mentation"
e. "What was the patient doing at the time of the fall? Patient was found on the floor sitting on her buttocks - she stated she was trying to use the restroom"
f. "New interventions documented after the fall? Red socks, bed alarm, move closer, bed alarming working"
g. "Where did the fall occur? Patient room"
h. "Was the fall witnessed? No"
i. "Injury: abrasion, bruise/hematoma, fracture/dislocation, laceration, pain whole left side"
j. "What could we have done differently? Bedside report, placed eyes on patient when patient brought to unit, tell buddy to put eyes on patient, inform tech patient was here"
k. "Preventable? ICU staff to do bedside report/handoff; do not leave pt bed in high position, no bed alarm"

Other documents regarding the patient's fall was reviewed and noted, "ICU staff did not communicate to transporting staff the fall risk of the pt. ICU transporting staff left the bed in a high position with her personal items out of reach. ICU transporting staff did not wait for IMCU receiving staff and did not escalate transfer of care to the charge nurse. This leaving the pt unassessed with no bed alarm in place."

Staff #3 was interviewed on 9/25/18. Staff #3 was asked what they recalled about the patient's fall and findings of the facility's investigation. Staff #3 stated, "Two of the ICU nurses transferred the patient to the IMCU. They didn't wait for the receiving IMCU nurse because they had to get back quickly to the ICU. The receiving IMCU nurse was busy at the time trying to d/c a central line from another patient and it took longer than anticipated to complete. The patient was left in the room by herself, the bed was left in a high position and the call light was not within reach. When the IMCU nurse came into the patient's room, they found the patient on the floor with injuries to the left side of the body. The patient ended up with a laceration to her left ear and an elbow injury."

In an interview with Staff #1 on the afternoon of 9/25/18 Staff #1 acknowledged the finding above.