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 record review and interview, the facility failed to ensure the provision of patient care in accordance with needs and staff responsibilities for 1 of 1 patients.

Failure to ensure the provision of patient care in accordance with needs and staff responsibilities created risk for patient injury, disability and death.

Findings included:

1. a. Review of the medical record of Patient #1 showed that the patient was evaluated and treated in the Emergency Department on 12/08/18 and admitted to the hospital. He was diagnosed with bilateral brain hemorrhages. The patient had surgery to treat the hemorrhages on 12/09/18. A few days later, he was alert, oriented, moving all extremities and following commands and was up to the chair more than once with assistance.

b. On 12/10/18 at 9:00 PM, the patient had a scheduled Fall/Harm assessment. There were 9 noted interventions required to prevent falls at that time. The patient assessment showed the patient scored as a high fall risk. The patient had an unwitnessed fall from the bed to the floor between 4:05 - 4:30 AM the next day. Post-fall huddle and assessment documents were not available for reference. During this period, the patient was in acute care status (not critical care status) while located on a critical care unit (CCU).

c. The patient became unresponsive and also suffered a head laceration. Imaging showed that he developed another brain bleed and staff rushed him emergently back to the operating room to remove some of the accumulation of acute blood. On December 15th, the family decided to transition the patient to comfort care based on his level of response to treatment and the patient died on [DATE].

2. a. On 02/14/19 at 9:30 AM, the investigator interviewed the Interim Nurse Manager (Staff A) of the CCU where the patient received care and fell about her findings in follow-up (beginning with when she received a notification phone call about the patient care event). She stated that at the time of the patient fall, the patient's nurse was off the floor in the Radiology department with another patient. When the nurse exited the CCU to go to Radiology, she gestured to nurses standing at the unit desk and stated that she was going to Radiology department and was leaving Patient #1.

b. Other information gathered by Staff A after the event indicated that the nurse did not report specifically to any nurse or the charge nurse on the clinical status of Patient #1 (including fall risk) before departing to the Radiology department. The patient was due for his next vital signs check at 4:00 AM (just prior to the time of the fall).

3. a. Record review of facility policy titled, "Patient Care Communications" (Policy #5.80; reviewed 09/2016) showed it included information about caregiver-to-caregiver reports. The content was general. Under a section about temporary hand-offs, it stated that communications "allowed for" exchange of pertinent risk information, such as fall risk.

b. Record review of a hand-off forms (no form #; no date) for CCU and acute care units was completed. The purpose of the two forms was to aid nurses in giving information to other nurses on the next shift or for when patients were transferred from one unit to the next unit. Both forms contained an area for information about patient fall harm risk.

4. a. On 02/14/19 at 2:00 PM the investigator interviewed the Associate Chief Nursing Officer (Staff B). She stated that the facility did not have a policy and procedure about standards of care for patients who "boarded" on a unit and received a different standard of care than most other patients on that unit. For example, hospital assistants on acute care units were routinely responsible for conducting patient safety rounds with nursing but, at the time of the event, hospital assistants in the CCU (of interest) were not routinely responsible for patient safety rounds, including while a patient's nurse was off of the critical care unit.

b. 1. During the same interview, Staff B indicated that the facility job description for hospital assistants in that CCU did not include performing patient safety rounds.

b.2. Review of the job description titled, "Hospital Assistant" (for 2WH NICU) did not indicate that safety rounds were performance standards. However, it stated "Provides safe/therapeutic care consistent with practice standards".

c. On 02/14/18 at 1:15 PM during an interview with the charge nurse of a critical care unit (Staff C), she stated that it was her practice, when she departed the patient care area, to provide a report about her patients' status/needs directly to another nurse and to the charge nurse.