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.

SSM ST CLARE HEALTH CENTER 1015 BOWLES FENTON, MO 63026 Aug. 7, 2019
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, record review, and policy review, the facility failed to ensure ongoing nursing assessment, interventions, and oversight to meet the patient's care/services and/or prevention of complications for:
- Six current fall risk patients (#1, #2, #3, #10, #12 and #13) and two discharged fall risk patients (#25 and #24) of 17 fall risk patients reviewed. (A-395)
- One current patient (#11) with a tracheostomy (an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lung) of one patient reviewed with a tracheostomy. (A-395)
- One current patient (#12) with a chest tube (flexible tube place in chest wall to remove air or fluid) of one patient reviewed with a chest tube. (A-395)
The facility also failed to develop, update and/or carry out care plans for six current patients (#1, #2, #4, #10, #11 and #12), and two discharged patients (#24 and #25), of 17 reviewed. (A-396)
These failures to provide a safe environment, and the lack of adequate evaluation and supervision of patient safety needs, had the potential to affect all patients at the facility. The facility census was 139.

See the 2567 A-395 and A-396 for further details.

The severity and cumulative effect of these failures resulted in the facility being out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, record review, and policy review, the facility failed to ensure ongoing nursing assessment, interventions and oversight met the patients' care/services and/or prevention of complications for:
- Six current fall risk patients (#1, #2, #3, #10, #12 and #13) and two discharged fall risk patients (#24 and #25) of 17 fall risk patients reviewed.
- One current patient (#11) with a tracheostomy (an opening created in the neck in order to place a tube into a person's windpipe that allows air to enter the lung) of one patient reviewed with a tracheostomy.
- One current patient (#12) with a chest tube (flexible tube place in chest wall to remove air or fluid) of one patient reviewed with a chest tube.
These failures to provide a safe environment, and the lack of adequate evaluation and supervision of patient safety needs, had the potential to affect all patients at the facility. The facility census was 139.

Findings Included:

1. Review of the facility's policy titled, "Patient Fall Prevention," revised 08/14/18, showed the directives to document assessment of fall risk and fall prevention interventions at admission, daily, when the patient's condition changes/changes in level of care, four hours prior to discharge, and/or after a patient's fall. Assessment and interventions will include:
- Complete the facility specific fall risk assessment scale.
- All patients were at universal risk for falls which requires universal interventions, bed low position, room free from clutter, assure use of call light, non-skid footwear, and identify fall risk patients in hand-off communications.
- Reference of the facility specific fall material, which requires interventions that corresponds with the level of risk assessed.
- Document on the assessment on the Adult Assessment or facility specific Fall Risk Assessment flowsheets in the electronic health record. (EHR)

Review of the undated facility specific fall risk assessment scale, showed the following level of scoring and interventions:
- Low fall risk (score 7-10) requires low interventions including green fall precaution signage outside the patient's door.
- Moderate fall risk (score 11-14) requires low and moderate interventions, including a yellow fall precaution signage outside the patient's door.
- High fall risk (score 15 or greater) requires low, moderate, and high interventions, including a red fall precaution signage outside the patient's door.

Review of the facility provided number of falls for 2018 were 151 falls (a ratio of one fall every two days).

During an interview on 08/06/19 at 4:10 PM, Staff CC, Fall Champion, stated that:
- In 06/2018, the facility had an upward trend in falls, one with injury, and noticed inconsistency with fall risk interventions based on the level of fall risk assessed.
- In 2018, the facility had 151 falls, which was a fall every other day, and "that was too high and unacceptable."
- The basic fall risk indicators included appropriate level of fall risk signage inside/outside the patient's room, a yellow arm band, yellow nonskid socks, and a bed alarm.
- Yellow nonskid socks were a visual identifier that the patient was at risk for falls.

Review of the facility's generic orientation fall prevention education for agency nursing, new nurse, care partner (technician) and physical therapist, showed inconsistency with the fall risk identifiers. Agency nursing, new nurses, and physical therapists did not receive fall prevention education related to the use of yellow non-skid socks.

Review of Patient #25's History and Physical (H&P) dated 05/03/19, documented that the patient was a [AGE] year old male with a history of hypertension (high blood pressure) and Parkinson's disease (disorder of the central nervous system that affects movement and often includes tremors) that presented to the Emergency Department (ED) with a chief complaint of nausea and vomiting after he started a laxative (medication to remove stool from the body) to prepare for a procedure scheduled the next day. The patient was dehydrated (a low body fluid volume) and had hypokalemia (a low potassium level in the blood). The patient was admitted for electrolyte imbalance, dehydration and symptom control overnight.

Review of the ED nurse's flowsheet, dated 05/03/19 at 3:09 AM, documented the facility specific fall risk assessment score was 14, which indicated the patient was a moderate risk for a fall.

Review of the ED nurse's flowsheet, dated 05/03/19, showed no documentation that falls risk interventions were implemented.

Review of the nurse's flowsheet dated 05/03/19 at 7:43 AM and 8:21 AM, documented the facility specific fall risk assessment score was seven, which indicated the patient was changed to a low risk for a fall.

Review of the nurse's flowsheet dated 05/03/19 at 7:43 AM and at 8:21 AM, documented the falls risk interventions were implemented and included a fall armband, signage placed on the outside of the patient's door, and the prevention precautions were reviewed with the patient and family. No documentation indicated yellow non-skid socks were used.

Review of the Significant Event Note, dated 05/03/19 at 12:44 PM, showed that the patient had an unwitnessed fall at 11:45 AM, and was found on the floor next to the bed with physical injury and deformity to the right leg.

Review of the X-ray of the right hip and pelvis (area around and between the hip bones) dated 05/03/19, showed a right hip fracture.

Review of the orthopedic surgeon's consultation note, dated 05/03/19 at 2:37 PM, documented that the patient had a right hip fracture that would require surgical repair the next morning.

Review of the Nurse's flowsheet, dated 05/03/19 at 12:06 PM, documented the facility specific fall risk assessment score was 15, which indicated the patient was changed to high risk for a fall. The flowsheet also showed that the falls risk intervention "alarm on" was "not applicable," although the patient had just fallen, and was determined to be at high risk for fall.

During a telephone interview on 08/07/19 at 12:40 PM, Staff JJ, Registered Nurse (RN), stated that:
- There were no fall precautions implemented for the patient prior to the fall.
- The patient was found on the floor without non-skid socks on, no floor mats, no fall armband and no bed alarm in place.
- A patient with a fall risk score that indicated a low risk for fall, should at a minimum have a sign outside the door of the room, a sign inside the room by the bathroom, non-skid socks on and a fall armband.

During an interview on 08/06/19 at 2:30 PM, Staff M, RN, stated that if a patient was documented as low risk, but believed to be at higher risk, the nurse could use their nursing judgement and indicate the patient was at a higher risk for fall and why, and implement more precautions. Staff M added that yellow socks indicated a patient was a fall risk.

During an interview on 08/07/19 at 2:00 PM, Staff D, Vice President of Nursing, stated that:
- She spoke to the RN who cared for Patient #25 when he arrived to the patient care unit and did the initial fall risk assessment. The nurse thought because the patient had treatment started to correct the electrolyte imbalance, it was no longer a problem to indicate on the facility specific fall risk assessment. Therefore, the score came back that the patient was a low fall risk.
- She agreed that the electrolyte imbalance was a problem at the time of admission, that it was the reason for the patient's admission to the hospital and should have been assessed as a problem on the facility specific fall risk assessment, which would have changed the precautions implemented for the patient.
- She agreed that the nurses were able to use their nursing judgement if the facility specific fall risk assessment score indicated no fall risk or a low fall risk, and they felt the patient was at increased risk.

During an interview on 08/06/19 at 4:10 PM, Staff CC, Fall Champion Team Leader, stated that:
- A patient who had Parkinson's disease should have been assessed at a higher risk for falls, based on the diagnosis.
- The nurse should have used nursing judgement when Patient #25 was assessed and the facility specific fall risk assessment indicated a low fall risk.
- More interventions were needed for Patient #25, such as fall mats and a bed alarm.

During a telephone interview on 08/07/19 at 12:30 PM, Staff II, RN, stated that nursing judgement could have been used with any patient if the fall risk score came out low and they felt a patient was at risk for a fall.

Review of Patient #25's orthopedic surgeon's operative note, dated 05/04/19, at 10:53 AM, showed that the surgeon was informed that after the patient's surgery was completed, the patient fell from the operating table, was caught by staff and lowered to the floor without injury.

During an interview on 08/07/19 at 9:10 AM, Staff EE, Anesthesiologist, stated that the facility process was to place a safety strap over a patient to safely secure the patient to the surgical table prior to the administration of anesthesia (insensitivity to pain, as administered by inhaled gas or the administration of drugs before or during a surgical procedure). However, a safety strap was not used for the type of surgery Patient #25 had on a fracture table (special, narrow table used in surgical repair of hip fractures), and therefore was not used on Patient #25. The patient began to fall off the table and Staff FF, First Assistant (surgeons assistant) caught him against the table, and the patient was lowered to the floor by surgical staff.

During an interview on 08/07/19 at 10:05 AM, Staff FF, First Assistant, stated that a safety strap was not used on Patient #25, and when he began to fall off of the table, he caught the patient, and the patient was assisted to the floor by surgical staff.

During an interview on 08/07/19 at 10:20 AM, Staff GG, Circulating Nurse, stated that safety straps were never used on the fracture bed. Staff GG also stated that a fall from a surgical table was considered a "never event" and that it should never have occurred.

During an interview on 08/07/19 at 9:30 AM, Staff DD, Director of Surgical Services, stated that she expected her staff to have used safety straps on every surgery.

The facility failed to implement safety interventions for Patient #25, which resulted in two falls, one with injury that required surgical intervention. The patient was unable to return home at the time of discharge, and required further therapy in a skilled nursing facility.

Review of Patient #24's H&P dated 04/13/19, showed that she was a [AGE] year old female admitted to the facility on [DATE], for a revision (to change or redo) of her left total knee arthroplasty (TKA, a surgical procedure in which the damaged parts of the knee joint are replaced with artificial parts). Patient #24 had experienced symptoms that included pain with daily activity that limited her ability to walk and navigate stairs and a decrease in her range of motion (ROM). The lack of stability with ambulation resulted in a staggered gait at times which posed a safety issue and put the patient at risk for falls.

Review of Patient #24's fall risk assessment dated [DATE] at 6:31 AM, showed that the patient was not a fall risk with a score of six, and no interventions implemented despite the documented reason for admission was for instability with ambulation that put the patient at risk for a fall.

During a concurrent record review and interview on 08/06/19 at 1:55 PM, Staff L, Post-surgical Unit Director, stated that she agreed that this patient's fall risk assessment was inaccurately assessed on admission, according to what the surgeon documented, and it placed the patient at risk for a fall.

Review of Patient #1's H&P dated 08/01/19, showed that she was a 73 year female admitted to the facility on [DATE] with shortness of breath, and lower leg swelling. Patient #1 had weakness, and was given a diuretic (medication to increase passing of urine).

Review of Patient #1's fall risk assessment dated [DATE] at 8:12 AM, showed that the patient was a moderate fall risk with a score of 13, and the fall risk signage was placed on the outside door.

Observation on 08/05/19 at 2:40 PM, in Patient #1's room, showed the patient with high fall alert signs on her door and inside the room, and the patient had on gray non-skid socks.

During an interview on 08/05/19 at 2:55 PM, Staff G, RN, stated that:
- She had assessed and scored Patient #1 as a moderate fall risk, and should have changed the signage on the outside door and inside the room from high fall risk to moderate fall risk.
- The gray socks were a visual aid to show the patient was a moderate fall risk (the facility did not use gray socks as a visual indicator for falls).
- The fall interventions in the room were inconsistent with the fall risk level assessment.

Review of Patient #2's H&P dated 08/02/19, showed that she was a 70 year female admitted to the facility on [DATE] with a stroke (occurs if the flow of oxygen-rich blood cannot reach a portion of the brain) and lethargy (weak, sluggish), and had some [DIAGNOSES REDACTED] (muscles that were continuously contracted and/or stiff).

Review of Patient #2's fall risk assessment dated [DATE] at 7:44 AM, showed that the patient was a moderate fall risk with a score of 13, and the fall risk signage was placed on the outside door.

Observation on 08/05/19 at 2:50 PM, in Patient #2's room, showed the patient with high fall alert signs on her door and inside of the room, and the patient did not have on yellow non-skid socks.

During an interview on 08/05/19 at 2:55 PM, Staff G, RN, stated that:
- She had assessed and scored Patient #2 as a moderate fall risk, and should have change the signage on the outside door and inside the room from high fall risk to moderate fall risk.
- Patient #2 did not have on yellow, non-skid socks, and she should have.
- The fall interventions in the room were inconsistent with the assessment.

Review of Patient #3's H&P dated 07/31/19, showed that he was a [AGE] year old male admitted to the facility on [DATE], with abdominal pain and diarrhea. Patient #3 had a left below the knee amputation (removal of an injured or diseased body part) and a history of falls.

Review of Patient #3's fall risk assessment dated [DATE] at 8:08 AM, showed that the patient was a high fall risk with a score of 16.

Observation on 08/05/19 at 3:05 PM, in Patient #3's room, showed the patient did not have on a yellow non-skid sock.

During an interview on 08/05/19 at 3:06 PM, Patient #3 stated that the staff had not offered him yellow nonskid socks since he was admitted five days ago.

During an interview on 08/05/19 at 3:10 PM, Staff J RN, stated that she had assessed and scored Patient #3 as a high fall risk and he should have had a yellow, non-skid sock on.

During an interview on 08/05/19 at 3:18 PM, Staff F, Team Leader, stated that the nursing staff should have fall risk interventions in place that were consistent with the patient's fall risk assessments.

Review of Patient #10's H&P dated 08/03/19, showed that he was a [AGE] year old male admitted to the facility on [DATE] with shortness of breath. Patient #10 appeared chronically ill (long term illness), and was very lethargic (weak, sluggish).

Review of Patient #10's fall risk assessment dated [DATE] at 8:00 AM, showed that the patient was a high fall risk with a score of 20, and the fall risk signage was placed on the outside door.

Observation on 08/06/19 at 8:46 PM, in Patient #10's room, showed the patient with high fall alert sign on the door and a moderate fall risk sign inside the room.

During an interview on 08/06/19 at 8:55 AM, Staff T, RN, stated that she had assessed and scored Patient #10 as a high fall risk, and that the fall risk interventions inside the room were not consistent with her assessment.

Review of Patient #12's H&P dated 08/03/19, showed that he was a [AGE] year old male admitted to the facility on [DATE] with increased shortness of breath. A chest x-ray showed pleural effusion (fluid buildup between the lungs and chest wall). Patient #12 required a chest tube.

Review of Patient #12's fall risk assessment dated [DATE] at 8:45 AM, showed that the patient was a high fall risk with a score of 17.

Observation on 08/06/19 at 9:56 AM, in Patient #12's room, showed the patient with three chest tubes and low fall risk signage outside the door and inside the room.

During an interview on 08/06/19 at 10:05 AM, Staff V, RN, acknowledged the low fall risk signage, and stated that Patient #12 was a low fall risk (the low fall risk was inconsistent with the nursing assessment of high risk for fall assessed by Staff V).

Review of Patient #13's H&P dated 07/31/19, showed that he was a [AGE] year old male admitted to the facility on [DATE] with shortness of breath. Patient #13 had a history of a fall.

Review of Patient #13's fall risk assessment dated [DATE] at 00:51 AM, showed that the patient was a moderate fall risk with a score of 14 and the signage was placed on the outside door.

Observation on 08/06/19 at 11:06 AM, in Patient #13's room, showed the patient with high fall alert signs on the door and a low risk sign inside of the room.

During an interview on 08/06/19 at 11:10 AM, Staff W, RN, acknowledged the high risk signage on the door and low risk signage inside the room, and stated that the fall interventions in the room were inconsistent with the assessment.

During an interview on 08/06/19 at 11:15 PM, Staff S, Team Leader, stated that the nursing staff should implement fall risk interventions that were consistent with the patient's fall risk assessments.

During an interview on 08/05/19 at 4:00 PM, Staff D, Vice President of Nursing, stated that the fall interventions should be consistent with the fall risk assessment.

The inaccurate assessment of the patients' fall risk assessments, and the inconsistent implementation of falls risk precautions and intervention, placed patients in all patient care areas at high risk for fall and injury.

2. Review of the facility's policy titled, "Tracheostomy Management: Adult Patients and Artificial Airway," dated 08/01/2017, showed the directives to provide safe and standardized procedures which included extra tracheostomy tubes (same size/type and one size smaller) at the bedside.

Review of Patient #11's H&P dated 08/04/19, showed that he was a [AGE] year old male admitted to the facility on [DATE], with primary history of tracheostomy with increased shortness of breath.

Observation on 08/06/19 at 9:05 AM, in Patient #11's room, showed the patient with tracheostomy tube and no extra tracheostomy tubes in the room.

During an interview on 08/06/19 at 9:10 AM, Staff Y, RN, acknowledged that there was no extra tracheostomy tubes in Patient #11's room. Staff Y stated that the nursing staff should have had extra tacheostomy tubes in the room per facility policy.

Even though requested, the facility did not provide a policy on chest tubes, and referenced a nationally recognized nursing skill publication for directives.

3. Review of the facility's generic chest tube maintenance care plan template, showed an intervention for staff to keep chest tube clamps (used to clamp the chest tube tubing to check for leaks in the closed chest tube system, and prevent the escape of air or fluid which can increase the risk of a Tension Pneumothorax [life threatening condition from the build up of air or fluid in the chest wall, preventing the ability to breath air into the lung]).

Review of Patient #12's H&P dated 08/03/19, showed that he was a [AGE] year old male admitted to the facility on [DATE] with increased shortness of breath. Chest x-ray showed a pleural effusion. Patient #12 required a chest tube intervention.

Observation on 08/06/19 at 9:56 AM, in Patient #12's room, showed the patient with three chest tubes, and no chest tube clamps at the bedside or in the room.

During an interview on 08/06/19 at 10:05 AM, Staff V, RN, acknowledged that there were no chest tube clamps at the bedside in Patient #12's room. Staff V stated that the nursing staff should have chest tube clamps at the bedside per the facility's chest tube maintenance care plan template.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, record review, and policy review, the facility failed to develop, update and/or carry out care plans for six current patients (#1, #2, #4, #10, #11 and #12), and two discharged patients (# 24 and #25), of 17 reviewed. These failures had the potential to affect all patients by having unidentified patient needs which could lead to poor patient outcomes. The facility census was 139.

Findings included:

1. Review of the facility's policy titled, "Care Planning," dated 11/08/18, showed the directives to provide overall guidelines for planning individualized care for patients receiving care, treatment, or services which included:
- The definition of care plan was to outline the interdisciplinary care to be provided to a patient.
- The care plan was a set of actions to be implemented to resolve problems identified by initial and ongoing assessments.
- The Registered Nurse (RN) was responsible for development/revision of the nursing aspect of care.
- The care plan process must ensure nursing staff develops and keeps current a care plan for each patient.
- The care plan process needed to be consistent with the nursing assessment.
- The care plan documentation process needed to select the appropriate template and/or appropriate goals based on assessment/reassessment and document in the care plan section.

Review of the facility's policy titled, "Patient Fall Prevention," revised 08/14/18, showed the directives to document care planning by the facility specific care plan resource template, which included:
- Level of risk;
- Patients individual risk factors;
- Interventions level risk; and
- Care plans will be documented under the care plan activity in the electronic medical record (EHR) and pulled into the plan of care notes.

Review of the undated the facility specific fall risk assessment scale showed the following level of scoring and interventions:
- Low fall risk (score 7-10) requires low interventions including green fall precaution signage outside the patient's door.
- Moderate fall risk (score 11-14) requires low and moderate interventions, including a yellow fall precaution signage outside the patient's door.
- High fall risk (score 15 or greater) requires low, moderate, and high interventions, including a red fall precaution signage outside the patient's door.

Review of the facility provided number of falls for 2018 were 151 falls (a daily ratio of one fall every two days).

During an interview on 08/06/19 at 4:10 PM, Staff CC, Fall Champion, stated that:
- In 2018, the facility had 151 falls, which was a fall every other day, and "that was too high, and unacceptable".
- In 06/2018, the facility had an upward trend in falls, one with injury, and noticed inconsistency with fall risk interventions based on the level of fall risk assessed.
- The basic fall risk indicators were appropriate level of fall risk signage inside/outside the patient's room, a yellow arm band, yellow nonskid socks, and a bed alarm.
- Yellow nonskid socks were a visual identifier that the patient was at risk for falls.

Review of the select rehabilitation committee working minutes, dated 02/13/19, showed interdisciplinary fall prevention which included that nursing identified fall risk and implemented care plans with targeted interventions. Knowing the patient's fall risk level (low, moderate, high) and underlying risk factors helped support bedside clinical efforts to prevent falls.

Review of Patient #1's care plan, signed 08/05/19 at 1:35 AM, showed Patient #1 was high risk for falls, with a bed alarm and yellow socks in place.

Review of Patient #1's fall risk assessment dated [DATE] at 8:12 AM, showed that the patient was a moderate fall risk with a score of 13.

Observation on 08/05/19 at 2:40 PM, in Patient #1's room, showed the patient with high fall alert signs on the door and inside of the room, and the patient was not wearing yellow, non-skid socks.

During an interview on 08/05/19 at 2:55 PM, Staff G, RN, stated that the care plan showed high risk for falls, and she did not update the care plan to the proper level of fall risk. Staff G also stated that the fall interventions in the room were inconsistent with the care plan.

Review of Patient #2's care plans, signed 08/05/19 at 3:05 AM, showed Patient #2 was at high risk for falls. Documentation showed interventions performed was a fall mat on the floor, bed alarm in place, fall socks on and correct signage displayed.

Review of Patient #2's fall risk assessment dated [DATE] at 7:44 AM, showed that the patient was a moderate fall risk with a score of 13, and that signage was placed on the outside door.

Observation on 08/05/19 at 2:50 PM, in Patient #2's room, showed the patient with high fall alert signs on the door and inside of room, and the patient did not have on yellow nonskid socks.

During an interview on 08/05/19 at 2:55 PM, Staff G, RN, stated that the care plans showed high risk for fall, and she did not update the care plan to proper level of fall risk.

During an interview on 08/05/19 at 3:18 PM, Staff F, Team Leader, stated that the staff should have updated the care plan to include the correct fall risk level. The care plan template had interventions listed on the care plan that would help staff to provide fall risk interventions that were consistent with the fall risk level assessed.

Review of Patient #4's care plan signed 08/03/19, showed Patient #4 was at moderate risk for falls. Documentation showed interventions performed was a yellow (moderate) fall precaution signage outside the door.

Review of Patient #4's fall risk assessment dated [DATE] at 8:01 AM, showed that the patient was a high fall risk with a score of 18, and that signage was place on the outside door.

Observation on 08/05/19 at 3:55 PM, in Patient #4's room, showed the patient with high fall alert sign on the door and a moderate fall risk sign inside the room.

During an interview on 08/05/19 at 3:58 PM, Staff K, Team Leader, stated that the nursing staff should have the fall risk interventions that were consistent with the patient's fall risk assessments. The staff should update the care plan to include the appropriate fall risk.

Review of Patient #10's fall risk assessment dated [DATE] at 8:00 AM, showed that the patient was a high fall risk with a score of 20, and that signage was placed on the outside door.

Review of Patient #10's care plans on 08/06/19 at 8:51 AM, showed no risk for falls.

Observation on 08/06/19 at 8:46 AM, in Patient #10's room, showed the patient with a moderate fall risk sign inside the room.

During an interview on 08/06/19 at 8:55 AM, Staff T, RN, stated there was not a fall risk care plan for Patient #10, and the nursing staff should have implemented a fall risk care plan.

Review of Patient #24's fall risk assessment, dated 04/15/19 at 10:55 AM, showed that the patient was a moderate fall risk with a score of 11.

Review of Patient #24's fall risk assessment, dated 04/15/19 at 9:11 PM, showed that the patient was a moderate fall risk with a score of 12.

Review of Patient #24's nurse care plans from admission on 04/15/19 through discharge on 04/18/19, showed no care plans were initiated for her fall risk assessed.

During a concurrent record review and interview on 08/06/19 at 2:00 PM, Staff M, RN, stated that there was no care plan initiated for this patient from admission to discharge.

During a concurrent record review and interview on 08/06/19 at 1:55 PM, Staff L, Director of the Post-surgical Unit, stated that a care plan should have been initiated on each patient with a fall risk assessment score of greater than six.

Review of Patient #25's H&P, dated 05/03/19, documented that the patient was a [AGE] year old male with a history of hypertension (high blood pressure) and Parkinson's disease (disorder of the central nervous system that affects movement and often includes tremors) that presented to the Emergency Department (ED) with a chief complaint of nausea and vomiting after he started a laxative to prepare for a procedure scheduled the next day. The patient was dehydrated (a low body fluid volume) and had hypokalemia (a low potassium level in the blood). The patient was admitted for electrolyte imbalance, dehydration and symptom control overnight.

Review of Patient #25's ED nurse's flowsheet, dated 05/03/19 at 3:09 AM, documented the fall risk assessment score was 14, which indicated the patient was at high risk for a fall.

Review of Patient #25's ED nurse's flowsheet, dated 05/03/19, showed no documentation that falls risk interventions were implemented.

Review of Patient #25's Inpatient nurse's flowsheet, dated 05/03/19 at 7:43 AM and at 8:21 AM, documented the fall risk assessment score was seven, which indicated the patient was changed to a low risk for a fall.

Review of the Nurse's Care Plan, dated 05/03/19 showed no documentation that a care plan related to the patient at risk for falls was initiated.

Review of Patient #25's Inpatient nurse's flowsheet, dated 05/03/19 at 7:43 AM and at 8:21 AM, documented falls risk interventions were implemented, and included a fall armband, signage placed on the outside of the patient's door and the prevention precautions reviewed with the patient and family. There was no documentation that indicated yellow non-skid socks were used.

Review of the Significant Event Note, dated 05/03/19 at 12:44 PM, showed that Patient #25 had an unwitnessed fall at 11:45 AM, and was found on the floor next to the bed, with physical injury noted and deformity to the right leg.

Review of Patient #25's x-ray report of the right hip and pelvis (bones around and between the hips), dated 05/03/19, showed a right hip fracture.

Review of Patient #25's orthopedic surgeon's consultation note, dated 05/03/19 at 2:37 PM, documented that the patient had a right hip fracture that would require surgical repair.

During a telephone interview on 08/07/19 at 12:40 PM, Staff JJ, RN, stated that:
- She was the charge nurse for that unit, and was called and informed the patient was found on the floor.
- There were no fall precautions implemented for the patient prior to the fall.
- The patient was found on the floor without non-skid socks on, without floor mats in place, no fall armband and no bed alarm in place.
- A patient with a low risk for fall should at a minimum have had a sign outside the door of the room, a sign inside the room by the bathroom, non-skid socks on and a fall armband in place.
- There should have been a care plan for any patient that was at risk for a fall.

During an interview on 08/06/19 at 2:30 PM, Staff M, RN and Charge Nurse, stated that:
- A nurse could have implemented more fall precautions, based on clinical judgement.
- Yellow socks indicated a patient was a fall risk.
- There should have been a care plan related to the patient's fall risk initiated at the start of care.
- She agreed that a care plan would have listed interventions and precautions that should have been implemented when the patient was identified as a fall risk.

During an interview on 08/07/19 at 2:00 PM, Staff D, Vice President of Nursing, stated that a care plan should be completed for any patient with a fall risk.

Appropriate care plan and interventions were not implemented and resulted in a traumatic injury for the patient that required surgical intervention and recovery for the patient.

2. Review of the facility's policy titled, "Tracheostomy Management: Adult Patients and Artificial Airway," dated 08/01/2017, showed the directives to provide safe and standardized procedures which included extra tracheostomy tubes (same size/type and one size smaller) at the bedside.

Observation on 08/05/19 at 3:05 PM, in Patient #11's room, showed the patient with tracheostomy tube and no extra tracheostomy tubes in the room.

Review of the facility's generic tracheostomy care plan template showed an intervention for staff to keep equipment at bedside, including extra tracheostomy tube(s).

Review of Patient #11's care plan on 08/06/19 at 9:10 AM, showed no tracheostomy care plan.

During an interview on 08/06/19 at 3:10 PM, Staff Y RN, acknowledged that there was no extra tracheostomy tubes in Patient #11's room. Staff Y stated that the nursing staff should have initiated a tracheostomy care plan and followed the care plan interventions.

3. Even though requested, the facility did not provide a policy on chest tubes.

Review of the facility's generic chest tube maintenance care plan template showed an intervention for staff to keep chest tube clamps at the bedside. (clamps were to prevent the escape of air or fluid increasing the risk of Tension Pneumothorax [build up of air or fluid in chest wall preventing the lung to expand])

Observation on 08/06/19 at 9:56 AM, in Patient #12's room, showed the patient with three chest tubes and no clamps in the room.

Review of Patient #12's care plans on 08/06/19 at 10:00 AM, showed no care for chest tube maintenance.

During an interview on 08/06/19 at 10:05 AM, Staff V, RN, acknowledged that there was no chest tube clamps at bedside, and/or in Patient #12's room. Staff V stated that the nursing staff should have initiated a chest tube care plan and followed the care plan interventions.

During an interview on 08/06/19 at 11:15 PM, Staff S, Team Leader, stated that the nursing staff should update the care plans to the individualized care of the patient. The care plan template had interventions listed on the care plan that would help staff to provide interventions that directed care for the patient's needs.

During an interview on 08/05/19 at 4:00 PM, Staff D, Vice President of Nursing, stated that the care plans should be initiated and updated to meet the needs of the patient.