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 facility failed to ensure the immediate availability of a registered nurse for supervision of the bedside care provided by personnel in preventing of fall/injury of 1 (SP#1) out of 4 sample patients (SP).

Findings include:

Review of sample patient (SP) #1 Hospitalist Progress Notes dated 09/24/2019 at 10:29AM documented Assessment/Plan: Had assisted fall, mild low back pain, follow-up lumbar X-ray.

Review of SP#1 Post Fall Huddle Template dated 09/24/2019 at 1:55PM documented Sitter reinforced to call for assistance getting patient out the chair. Details of Fall: Changing diaper, patient stood up with sitter by side, feel weak, sitter unable to hold patient, assisted patient to floor.

Review of Progress Notes Generic dated 09/24/2019 at 2:42 PM documented House Advanced Practice Registered Nurse received call from nursing supervisor that patient "fell ." Per report while patient was standing sitter was completing placing diaper on patient when patient's feet "became weak" and sitter lowered patient on floor. Upon arrival to assess patient noted patient sitting in chair in no acute distress with clinical partner seated on bed next to patient. Patient reports right back pain and buttock pain after patient points to bed rail that patient contacted while being "lowered" to floor. Visualized an area lateral to patient's right thoracic extending to upper lumbar area with light "scratches" that appears tender to touch as evidenced by patient pulling away when lightly palpating that area. No bleeding, swelling or ecchymosis noted. Through translation patient also reports soreness to buttocks. Discussed with nurse, nursing supervisor and physician. Orders in progress: thoracic X-ray and lumbar X-ray 2 views (will include coccyx and sacrum per radiology). Results to be given to physician. Further management as per physicians.

Review of SP#1 Progress Note Generic dated 09/24/2019 at 11:35PM documented House Advanced Practice Registered Nurse responded to Registered Nurse called to notify patient was status post assisted fall earlier in the day. Now patient been complaining of mild aching headache at the left parietal/temporal area. Unable to quantify, no other neuro symptomatology present. Denies and chest pain, nausea, vomiting, visual or auditory changes, lightheaded. Patient currently awake, alert and oriented, mild chronic expressive aphasia due to history of stroke in the past as per daughter at bedside. Patient had radiologist work up earlier on back with now significant acute findings. Plan of Care: Orders: A (computed tomography scan) CT brain stat, X-ray to right shoulder. Patient already administered pain medication now as needed. Fall precautions, rails up X 3, call light within reach, sitter at bedside for safety.

Review of SP#1 Progress Notes Generic dated 09/25/2019 at 6:31PM documented Patient presents somewhat confused. When asking questions patient attempts to verbalize. However, unable to verbally articulate, or answer questions appropriately. As per daughter this is new. Patient was able to speak clearly prior to "the fall yesterday." Assessment/Plan: 2. Metabolic [DIAGNOSES REDACTED]: Altered mental status likely exacerbated in the setting of sepsis. Patient also with history of CVA (stroke) and dementia. Patient status post assisted fall the previous day. CT of the brain demonstrated multiple chronic ischemic changes. No acute parenchymal findings by CT. No change since the prior exam. No acute intracranial hemorrhage. Daughter currently visiting patient. Verbalizes patient is confused and this is new since the previous day after the assisted fall. As per daughter in the presence of nursing supervisor, patient was "speaking clearly." Will repeat brain CT in A.M. and obtain a neurology evaluation. 7. History of CVA with residual effect: As per daughter, patient with history of strokes in the past. Seen in the past by neurology. Per review of medical record as far as July 2015, patient with history of stroke and right [DIAGNOSES REDACTED]. As well as aphasia. 9. Status post fall: Patient with assisted fall the previous night. X-rays negative. Continue 1:1 sitter. As per daughter, patient presenting more confused since the previous day's incident. Will repeat chest x-ray and obtain a urinalysis with culture reflex. Repeat CT of the brain 24 hours post and obtain a neurology evaluation.

Review of SP#1 Nursing Narrative Notes dated 09/26/2019 at 4:40 AM documented at this time during rounds and vital signs, the patient was noticed to have an elevated blood pressure. The Advance Practice Registered Nurse was called and order received to for intravenous blood pressure medication. In the process, the patient had a change in mental status and excessive weakness on patient's extremities. A Code Rescue was called.

Review of Private Duty Certified Nursing Assistant (CNA)/Caregiver Job Expectations dated 10/2018 documented Essential Job Functions to include assessing the needs of the patient and evaluating how the needs are to be met. Private Duty sitters are expected to provide basic patient care as directed by the Registered Nurse. These include but are not limited to: a) Provide for patient safety.

Interview with Registered Nurse- Staff E on 10/29/2019 at 1:43PM revealed that staff remembers SP#1. Stated the patient's daughter requested patient to get out of bed. Stated there was an order from the pulmonologist for the patient to get out of bed. Stated assisted patient with the Clinical Partner to the chair. Stated the patient was sitting in chair and became wet. Stated the sitter changed the patient alone but patient was steady and did not need two person. Stated patient was changed and nurse went to look for someone to witness for insulin and then heard the sitter scream for help. Stated nurse saw patient sitting on floor. Stated patient was weak and sitter assisted patient to the floor.

Interview with Risk Manager on 10/29/2019 at 11:33 AM revealed Patient had a history of falls, fell prior to admission from the previous Sunday and had a bump on the head.

According to the interview the patient had a history of falls in the last 3 months. Patient had a diagnosis of [DIAGNOSES REDACTED]

Review of SP#1 Flowsheet dated 09/20/2019 at 9:39PM documented Falls Assessment. History of Fall in Last 3 Months Morse: No. Presence of Secondary Diagnosis Morse: Yes. Use of Ambulatory Aid Morse: None, bedrest, wheelchair, nurse. Gait Weak or Impaired Fall Risk Morse: Weak. Mental Status Fall Risk Morse: Oriented to own ability. Morse Fall Score: 45. Activities of Daily Living (ADLs): Moderate Assistance.

The Policy titled " Fall Prevention Program", (reviewed 10/20/2016) states all patients admitted to [ named] hospital
as inpatients or outpatients, will be assessed and reassessed for the risk of falling and procedures will be implemented in an effort to prevent falls. The policy further states We acknowledge that some patients may be at risk for falling although the risk assessment score did not reach the established threshold. Fall risk assessments and interventions shall be individualized to consider all contributing factors. All staff, including non-direct care staff is responsible for complying with the intent and procedures contained within this policy and for actively participating in creating a safe environment of care.