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.

ST ANTHONY'S SENIOR CARE HOSPITAL, LLC 2114 N. 127TH COURT EAST WICHITA, KS 67206 Aug. 27, 2020
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to provide personal privacy and maintain patient dignity for three of four patients reviewed (Patients 1, 2, and 3) as evidenced by the hospital's practice of placing patients on mattresses on the floor in the commons area (open area shared by all patients for dining and activities; staff in the nursing station can view patients in the area) of the hospital. Failure of the hospital to provide safe, private sleeping areas for each patient denied the patients their rights to personal privacy and dignity.

Findings Include:

Review of a hospital policy titled, "Fall Prevention Protocol" revised 03/01/20 showed: POLICY: All hospitalized patients are considered a fall risk and will be assessed to minimize their risk of falling. St. Anthony's Senior Care Hospital staff will work to actively reduce the risk of falls by ensuring a safe physical environment and appropriate identification of patients at risk for falls.

PROCEDURE: ENVIRONMENTAL AND HOSPITAL SAFETY. All hospital staff are responsible for reducing fall risks and ensuring a safe environment free from hazards. All clinical and non-clinical staff are aware of high fall risk patients and will work within their scope of practice to prevent patient falls. Staff work as a cohesive team to eliminate hazards, by involving Environmental Services and Engineering as appropriate ...

Review of hospital admission documents showed: All patients shall have the right to (which Include, but are not limited to the following):
... Considerate, dignified and respectful care, provided in a safe environment, free from all forms of abuse, neglect, harassment and/or exploitation.
...Full consideration of privacy concerning his/her medical care program. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly ...


Review of Patient 1's medical record showed an admission from 07/15/20 through 08/07/20. His admitting diagnosis was hallucinations, delusions, obsessive compulsive disorder (OCD), anxiety, harm to others, self-care deficit, and [DIAGNOSES REDACTED] (the second most common type of progressive dementia after Alzheimer's disease dementia and causes a progressive decline in mental abilities). Medical complications included hypertension (high blood pressure) and coronary artery disease (CAD) (blockage of major blood vessel).

The admission nursing assessment performed by Staff P, Registered Nurse (RN) on 07/15/20 showed his Morse fall score at 75, placing him at high fall risk and he had an unstable ambulation requiring ambulation with a wheelchair. Further fall risk documentation from 07/17/20 through 08/05/20 showed his score alternating from a low risk score of 25 to a high-risk score of 75.

The Initial Safety Treatment Plan dated 07/15/20 showed Patient 1 experienced chronic confusion, hallucinations, frequent attempts to get out of bed, and was exit seeking.

Review of the Nursing note narratives showed he was sleeping on a mattress on the floor in the commons area
on 07/15/20.

The hospital failed to provide Patient 1 reasonable privacy when they placed him in the commons area to sleep on a mattress which violates his right to respect, dignity, and comfort while in the hospital.


Review of Patient 2's medical record showed an admission of 08/06/20 to present. Her admitting diagnosis was depression, anxiety, harm to others, exit seeking, and dementia (loses the ability to think, remember, learn, make decisions, and solve problems). Symptoms may also include personality changes and emotional problems). Medical complications included hypertension, chronic obstructive pulmonary disease (COPD) (lung disease causing permanent lung damage), diabetes, and [DIAGNOSES REDACTED] (low [DIAGNOSES REDACTED]).


The admission nursing assessment performed by Staff B, RN, Director of Nursing (DON) on 08/06/20 documented her Morse fall scale assessment at 75, placing her at high risk for falls. Further nursing documentation from 08/06/20 through 08/21/20 showed no evidence of nursing fall assessments performed to assign a fall risk score.

Review of nursing note narratives showed Patient 2 was sleeping on a mattress on the floor in the commons area on the following dates and times:

1. 08/14/20 at 10:00 PM
2. 08/15/20 at 10:00 PM
3. 08/16/20 at 12:00 AM and 4:00 AM
4. 08/17/20 at 4:00 AM
5. 08/18/20 at 4:00 AM, 6:00 AM and 10:00 PM
6. 08/19/20 at 2:00 AM, 4:00 AM and 6:00 AM

The hospital failed to provide Patient 2 reasonable privacy when they placed her in the commons area to sleep on a mattress, which violates her right to respect, dignity, and comfort while in the hospital.


Review of Patient 3's medical record showed an admission from 07/16/20 through 08/21/20. His admitting diagnosis was harm to others, unspecified dementia, delusional disorder, adjustment disorder with depressed mood and anxiety, and generalized anxiety disorder. Medical complications included COPD, spinal stenosis, (abnormal narrowing of the spine placing pressure on spinal cord and nerve roots), benign prostate hyperplasia (BPH) (enlarged prostate gland), and Parkinson's disease (long term degenerative disorder of the central nervous system affecting the motor system).

The admission nursing assessment performed by Staff Q, RN on 07/16/20 documented a Morse fall risk score of 115, placing him at high fall risk noting he was very weak requiring full assist with transfers.

Review of nursing note narratives showed Patient 3 was sleeping on a mattress on the floor in the commons area on the following dates and times:

1. 07/16/20 at 6:30 PM
2. 07/17/20 at 7:20 PM
3. 07/18/20 at 4:45 AM
4. 07/19/20 at 6:00 AM
5. 07/20/20 at 6:00 AM
6. 07/23/20 at 12:00 AM
7. 07/24/20 at 12:00 AM
8. 07/25/20 at 4:00 PM and 6:00 PM
9. 07/26/20 at 4:00 AM
10. 07/28/20 at 6:00 PM
11. 08/01/20 at 4:00 AM, 6:15 AM, 8:00 AM and 10:00 PM
12. 08/02/20 at 12:00 AM, 4:00 AM, 6:00 AM and 10:00 PM
13. 08/06/20 at 2:00 PM and 10:00 PM
14. 08/07/20 at 12:00 AM, 8:00 AM and 9:55 PM
15. 08/09/20 at 10:00 PM
16. 08/10/20 at 12:00 AM, 8:00 PM and 10:00 PM
17. 08/11/20 at 2:00 AM, 4:00 AM, 6:00 AM, and 10:00 PM
18. 08/12/20 at 4:00 AM and 10:00 PM
19. 08/13/20 at 12:00 AM, 2:00 AM and 4:00 AM
20. 08/16/20 at 10:00 PM
21. 08/17/20 at 10:00 PM
22. 08/18/20 at 2:00 AM, 4:00 AM and 6:00 AM

The hospital failed to provide Patient 3 reasonable privacy when they placed him in the commons area to sleep on a mattress which violates his right to respect, dignity, and comfort while he was in the hospital.


During an interview on 08/26/20 at 1:15 PM, Physician Staff Z, Hospitalist, stated that the hospital does not have enough staff to provide one on one observation and senior psychiatric patients often require continuous higher observation levels. Staff Z, stated further, "the mortality rate of death following a fall in the frail elderly is much more of a concern than a fire safety issue or patient's dignity."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, document review, record review and interview, the hospital failed to ensure a Registered Nurse (RN) was on duty at all times and failed to ensure adequate numbers of nursing staff on the night shift to provide the level of observation and care needed to protect the safety and wellbeing of patients, as evidenced by the hospital's practice of placing patients assessed to be at risk for falls and/or with behaviors that could not be easily redirected on mattresses on the floor in the commons areas (open area shared by all patients for dining and activities; staff in the nursing station can view patients in the area) without a policies and procedures to guide the practice, creating a hazard that could potentially prevent patients and staff from safely exiting during a fire emergency situation, placing them at risk for injury and even death.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) situation.

The surveyor notified the hospital that an IJ existed on 08/27/20 at 8:50 AM, related to the Condition of Participation of Nursing Services at 42 CFR 482.23. The hospital submitted a credible plan of removal and the IJ was removed on 08/27/20 at 4:55 PM. The plan of removal included the following:

1. Fall Prevention Protocol policy revised to add language that St. Anthony's Hospital will not use mattresses on the floor in the common area or patient's room.

2. Development of Acuity Based Staffing Plan Policy #2006 and Adult Inpatient Psychiatric Acuity Tool implemented 08/27/20.

3. Educate all Professional Nurses on Adult Inpatient Psychiatric Acuity Tool and Staffing Plan (Policy #2006) will be delivered by 08/28/20.

4. Staffing based on acuity will continue to be evaluated every shift and as needed to determine staffing needs by the Director of Nursing (DON). Effective 08/27/20, the DON and trained professional nurses will implement and put into practice the Adult Inpatient Psychiatric Acuity Tool and Staffing Plan (Policy #2006).

5. The DON will effectively manage, and ensure the hospital is sufficiently staffed to provide safe quality care. The DON will appoint a designee when needed that has demonstrated competency through ongoing education and training regarding the acuity-based staffing plan (e.g., Infection Prevention Nurse, RN, RN Charge Nurses).

6. The Director of Nursing and CEO are working together to ensure Charge Nurses are properly trained and understand the Acuity Tool and Staffing Plan (#2006). (The Director of Nursing or Designee remains on call and available to respond to urgent and emergent needs).

7. Staffing variances tracking, and trending information will be presented to the Quality Committee, Medical Executive Committee and the Governing Board in a special session to be held 08/28/20.

Findings Include:


The Director of Nursing (DON) failed to ensure adequate nursing staff to provide the level of observation and care needed to protect the safety and wellbeing of patients. The DON supported the practice of placing patients on mattresses on the floor of the commons area without policies and procedures to guide nursing staff. (Refer to A-386 for further details).


The hospital failed to ensure adequate nursing staff to provide the level of observation and care needed to protect the safety and wellbeing of patients as evidenced by the hospital's practice of placing patients on mattresses on the floor in the commons area as an opportunity to prevent patient falls. (Refer to A-392 for further details).


The hospital failed to ensure a registered nurse (RN) was on duty and immediately available to patients and patient care staff at all times as directed by federal regulatory requirements and hospital policy. The hospital also failed to ensure two nurses were in the hospital every shift as directed by hospital policy. (Refer to A-393 for further details).
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, record review and staff interview the Director of Nursing (DON) failed to ensure adequate nursing staff were available on all shifts to provide safe and effective care to all patients. The DON was aware and supported the practice of placing patients on mattresses on the floor of the commons area (open area shared by all patients for dining and activities; staff in the nursing station can view patients in the area) without a policy and procedure to guide nursing practice for 3 of 4 patients reviewed (Patients 1, 2, and 3). The failure to ensure adequate nursing staff and to allow patients to sleep on mattresses in the commons area has the potential to place all patients at risk for unmet needs, harm, injury or even death.

Findings Include:

1a. Review of the hospital policy titled, "Staffing Guidelines" with an original date of 03/26/18, and revised 08/27/20, showed: The staffing pattern ensures the availability of a registered nurse 24 hours a day...The Hospital will maintain nurse staffing plans based on patient need and other influencing criteria such that: ...A minimum of two (2) nurses will be in the hospital on every shift, with the DON or designee available 24/7 on call availability...The DON or designee maintains 24-hour accountability for adequate staffing with responsibility for each shift delegated to the Charge Nurse and /or house supervisor/charge nurse...The Director of Nursing will direct the development and implementation of nurse staffing plans to sustain reasonable nurse to patient ratios.

1b. During an interview on 09/09/20 at 3:15 PM, Staff B, Regional DON, Registered Nurse (RN) stated the hospital policy regarding staffing includes staffing with a minimum of one RN on site during each shift and she further stated it is a regulatory requirement. She then stated an RN is always available by phone if not actually on site and the previous DON who left in July lived five minutes from the hospital. When a shift did not have an RN scheduled to cover, the DON would be available to come to the hospital if she were needed. She then stated that was not a common practice and occasionally with late call ins by scheduled staff it was not possible to replace them immediately, especially if staff from the previous shift were unable to stay over for the next shift. She further stated there could be lapses in the staffing on a shift until an RN was able to come in to fill the void. Licensed Practical Nurses (LPNs) are not to staff a shift without an RN for oversight and she clarified there should never be a reason a staff member would work without clocking in on the time clock.


2. Review of hospital documents titled, "Detailed Hours Overview" dated 07/01/20 through 07/25/20 and 08/09/20 through 08/22/20 showed there was not a Registered Nurse (RN) clocked in to work on the following shifts:


1. 07/03/20, 6:00 PM to 6:00 AM, the document showed: Staff S, LPN; Staff FF, Mental Health Technician (MHT); Staff GG, CNA; and Staff HH clocked in to work during this shift.

2. 07/13/20, 6:00 PM to 6:00 AM, the document showed: Staff R, LPN; Staff FF, MHT; and Staff X, CNA/LPN clocked in to work during this shift.

3. 07/24/20, 6:00 PM to 6:00 AM, the document showed: Staff R, LPN; Staff EE, LPN; and Staff GG, CNA clocked in to work during this shift.

5. 08/17/20, 6:00 PM to 6:00 AM, the document showed: Staff S, LPN; Staff X, LPN; Staff DD, CNA; and Staff GG, CNA clocked in to work during this shift.

6. 08/21/20, 6:00 PM to 6:00 AM, the document showed: Staff S, LPN; Staff X, LPN; and Staff DD, CNA clocked in to work during this shift.

7. 08/22/20, 6:00 PM to 6:00 AM, the document showed: Staff S, LPN; Staff X, LPN; Staff DD, CNA; and Staff FF, CNA clocked in to work during this shift.


3. Review of hospital documents titled, "Daily Census Sheet" and "Detailed Hours Overview" from 07/01/20 through 07/25/20 and 08/09/20 through 08/22/20 showed the following census and staffing pattern for the 6:00 PM to 6:00 AM shift that did not have two nurses staffed the entire shifts:

1. 07/01/20 - Patient census of 17 and staffing showed Staff J, RN; Staff FF, MHT; and Staff HH, clocked in to work during the 6:00 PM to 6:00 AM shift and Universal Worker (UW), who worked 6:00 PM to 10:00 PM. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

2. 07/03/20 Patient census of 13 and staffing showed Staff S, LPN; Staff FF, MHT; Staff GG, CNA; and Staff HH, UW clocked in to work during the 6:00 PM to 6:00 AM shift. The hospital did not have an RN scheduled this shift which is a federal regulatory and hospital policy requirement, nor did they have two nurses clocked in for the entire shift which is a hospital policy requirement.

3. 07/11/20 Hospital did not provide the census for this shift, staffing showed Staff J, RN; and Staff GG, CNA, clocked in to work during the 6:00 PM to 6:00 AM shift. The hospital did not have a second nurse scheduled this shift, which is a hospital policy requirement.

4. 07/12/20 Hospital did not provide the census for this shift, staffing showed Staff J, RN; Staff GG, CNA, clocked in to work during the 6:00 PM to 6:00 AM shift and Staff HH, UW, worked from 11:00 AM to 7:00 PM. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

5. 07/13/20 Patient census of 13 and staffing showed Staff R, LPN; Staff FF, MHT; and Staff X, CNA, clocked in to work during the 6:00 PM to 6:00 AM shift. The hospital did not have an RN scheduled this shift which is a federal regulatory and hospital policy requirement.

6. 07/15/20 Patient census of 13 and staffing showed Staff J, RN; Staff FF, MHT; Staff GG, CNA, clocked in to work during the 6:00 PM to 6:00 AM shift and Staff HH, UW, worked from 6:00 PM to 10:00 PM. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

7. 07/19/20 Hospital did not provide the census for this shift, staffing showed Staff J, RN clocked out at 2:37 AM, Staff FF, MHT, clocked in to work during the 6:00 PM to 6:00 AM shift and Staff HH, UW, worked from 11:00 AM until 7:00 PM. There were no other RNs or LPN's clocked in after 2:37 AM, The hospital did not have an RN scheduled the remainder of this shift which is a federal regulatory and hospital policy requirement.

8. 07/20/20 Patient census of 14 and staffing showed Staff J, RN, Staff X, CNA, and Staff GG, CNA clocked in to work during the 6:00 PM to 6:00 AM shift; Staff S, LPN worked from 6:00 AM until 11:00 PM. The hospital did not have a second nurse scheduled after 11:00 PM, which is a hospital policy requirement.

9. 07/21/20 Patient census of 13 and staffing showed Staff J, RN; Staff FF, MHT; and Staff X, CNA, clocked in to work during the 6:00 PM to 6:00 AM shift. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

10. 08/13/20 Patient census of 13 and staffing showed Staff J, RN; Staff CC, CNA; Staff FF, MHT; and Staff GG, CNA, clocked in to work during the 6:00 PM to 6:00 AM shift. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.


The DON failed to ensure adequate staffing levels by ensuring an RN was available on-site every shift as well as ensuring that two nursing staff were available each shift. The DON failed to have nurse staffing policies and procedures based on the intensity of illness and nursing needs of the patients, the physical layout and size of the hospital, the number of patients, the availability of other resources, and the training and experience of the personnel.



4a. Review of Patient 1's medical record on showed an admission of 07/15/20 through 08/07/20. His admitting diagnosis was hallucinations, delusions, obsessive compulsive disorder (OCD), anxiety, harm to others, self-care deficit, and [DIAGNOSES REDACTED] (the second most common type of progressive dementia after Alzheimer's disease dementia and causes a progressive decline in mental abilities). Medical complications included hypertension (high blood pressure) and coronary artery disease (CAD) (blockage of major blood vessel).

The admission nursing assessment performed by Staff P, Registered Nurse (RN) on 07/15/20 showed his Morse fall score at 75, placing him at high fall risk and he had an unstable ambulation requiring ambulation with a wheelchair. Further fall risk documentation from 07/17/20 through 08/05/20 showed his score alternating from a low risk score of 25 to a high-risk score of 75. Review of the nursing notes showed he fell on [DATE] at 8:20 PM, 07/21/20 at 6:00 PM, 07/25/20 at 6:00 PM.

The Initial Safety Treatment Plan dated 07/15/20 showed Patient 1 experienced chronic confusion, hallucinations, frequent attempts to get out of bed, and was exit seeking.

Review of the Nursing note narratives showed he was sleeping on a mattress on the floor in the commons area per physician orders on 07/15/20 at 8:30 PM.

However, the medical record lacked documented evidence of a signed physician's order to place the mattress on the floor in the commons area.

Documentation showed that Patient 1 slept on a mattress in the commons area on 07/15/20, a night that hospital staffing did not meet the minimum requirement to have two nurses in the hospital every shift .

Refer to A-0392 for further details.


4b. Review of Patient 2's medical record showed an admission of 08/06/20 to present. Her admitting diagnosis was depression, anxiety, harm to others, exit seeking, and dementia (loses the ability to think, remember, learn, make decisions, and solve problems). Symptoms may also include personality changes and emotional problems). Medical complications included hypertension, chronic obstructive pulmonary disease (COPD) (lung disease causing permanent lung damage), diabetes, and [DIAGNOSES REDACTED] (low [DIAGNOSES REDACTED]).

The admission nursing assessment performed by Staff B, RN, Director of Nursing (DON) on 08/06/20 documented her Morse fall scale assessment at 75, placing her at high risk for falls. Further nursing documentation from 08/06/20 through 08/21/20 showed no evidence of nursing assessments performed with an assigned fall risk score. Further documentation showed Patient 2 fell in the bathroom on 08/11/20 at 1:45 AM with no resulting injury.

Review of nursing note narratives showed Patient 2 was sleeping on a mattress on the floor in the commons area on the following dates and times:

1. 08/14/20 at 10:00 PM
2. 08/15/20 at 10:00 PM
3. 08/16/20 at 12:00 AM and 4:00 AM
4. 08/17/20 at 4:00 AM
5. 08/18/20 at 4:00 AM, 6:00 AM and 10:00 PM
6. 08/19/20 at 2:00 AM, 4:00 AM and 6:00 AM

The medical record lacked documented evidence of a signed physician order to place the mattress on the floor in the commons area for any of these dates.

Refer to A-0392 for further details.


4c. Review of Patient 3's medical record showed an admission from 07/16/20 through 08/21/20. His admitting diagnosis was harm to others, unspecified dementia, delusional disorder, adjustment disorder with depressed mood and anxiety, and generalized anxiety disorder. Medical complications included COPD, spinal stenosis, (abnormal narrowing of the spine placing pressure on spinal cord and nerve roots), benign prostate hyperplasia (BPH) (enlarged prostate gland), and Parkinson's disease (long term degenerative disorder of the central nervous system affecting the motor system).

The admission nursing assessment performed by Staff Q, RN on 07/16/20 documented a Morse fall risk score of 115, placing him at high fall risk noting he was very weak requiring full assist with transfers. Additional nursing assessments on 07/23/20 showed a fall risk score of 40, moderate fall risk, and a score of 75, high fall risk on 07/24/20.

The Initial Safety Treatment Plan dated 07/16/20 included fall risk due to impulsivity and fall risk score of 115, Goal - Decreased falls by following interventions daily for 14 days. Intervention - Nursing to assess fall risk every shift, mattress on the floor to decrease falls, close observation while awake to decrease falls, use a wheelchair for ambulation to decrease falls.

Review of nursing note narratives showed Patient 3 was sleeping on a mattress on the floor in the commons area, 22 of 37 days/nights during his hospital stay, on the following dates and times:

1. 07/16/20 at 6:30 PM
2. 07/17/20 at 7:20 PM
3. 07/18/20 at 4:45 AM
4. 07/19/20 at 6:00 AM
5. 07/20/20 at 6:00 AM
6. 07/23/20 at 12:00 AM
7. 07/24/20 at 12:00 AM
8. 07/25/20 at 4:00 PM and 6:00 PM
9. 07/26/20 at 4:00 AM
10. 07/28/20 at 6:00 PM
11. 08/01/20 at 4:00 AM, 6:15 AM, 8:00 AM and 10:00 PM
12. 08/02/20 at 12:00 AM, 4:00 AM, 6:00 AM and 10:00 PM
13. 08/06/20 at 2:00 PM and 10:00 PM
14. 08/07/20 at 12:00 AM, 8:00 AM and 9:55 PM
15. 08/09/20 at 10:00 PM
16. 08/10/20 at 12:00 AM, 8:00 PM and 10:00 PM
17. 08/11/20 at 2:00 AM, 4:00 AM, 6:00 AM, and 10:00 PM
18. 08/12/20 at 4:00 AM and 10:00 PM
19. 08/13/20 at 12:00 AM, 2:00 AM and 4:00 AM
20. 08/16/20 at 10:00 PM
21. 08/17/20 at 10:00 PM and
22. 08/18/20 at 2:00 AM, 4:00 AM and 6:00 AM

The medical record lacked documented evidence of a signed physician order to place Patient 3 on a mattress on the floor in the commons area for any of these dates.

Refer to A-0392 for further details.


4d. The hospital failed to provide a policy and procedure regarding the practice of placing patients on mattresses in the commons area to provide nursing staff easier observation of patients at risk for falls, who are demonstrating behaviors which place them at higher risk for falls, including obtaining a physician's order. Even though the hospital did not have a policy directing nursing staff to obtain a physician's order, it was a common and widespread understanding of the nursing staff that a physician's order was required to place these patients on mattresses in the commons room.

4e. During an interview on 08/24/20 at 8:30 AM, Staff B, Regional Director of Nursing (DON ) stated all direct patient care staff are responsible for performing environmental checks on every patient every 15 minutes, noting their location and activity. She confirmed mattresses are placed on the floor at night in the commons area for any patient who is assessed as a high fall risk and tends to get up unassisted or wander. She stated that placing the mattress on the floor helps reduce the risk of falls.

4f. During an interview on 08/24/20 at 4:30 PM, Staff B, Regional Director of Nursing (DON) further stated that after the hospital opened there was a high percentage of patient falls even with 15-minute checks. The nurses met with the DON at the time and Staff Y, Psychiatrist with an agreement between all staff and the psychiatrist to move mattresses onto the floor in the commons area if a high fall risk patient was not redirectable. She stated previously, the hospital attempted to place mattresses on the floor next to the bed, but the patients could not be continuously monitored. She clarified a physician order is required prior to placing the mattress on the floor.


The DON failed to ensure that a patient care policy and procedure was developed to guide nursing staff regarding how to provide appropriate supervision and observation of fall risk patients, demonstrating behaviors that are not easily redirectable. Nursing staff placed these patients on mattresses on the floor of the commons area so that they would be easier to observe. Nursing staff failed to obtain physician's orders to place patients on the mattresses and the DON failed to monitor this practice.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, and document review the hospital failed to provide adequate nursing staff to provide the level of observation and care needed to protect the safety and wellbeing of patients on the 6:00 PM to 6:00 AM shift for three of four patients reviewed (Patients 1, 2, and 3), who intermittently slept on mattresses on the floor in the commons area (open area shared by all patients for dining and activities; staff in the nursing station can view patients in the area). Failure of the hospital to provide sufficient staff levels to provide safe care placed all patients at risk of injury or death when placed on a mattress on the floor in the commons area to sleep.

Findings Include:

1a. Review of a hospital policy titled, "Staffing Guidelines", with an original date of 03/26/18, and revised 08/27/20, showed the staffing pattern will ensure the availability of a Registered Nurse 24 hours per day and a minimum of two nurses will be in the hospital every shift with the Director of Nursing (DON) or designee available 24/7 on call availability. The policy further showed the DON or designee maintains the 24-hour accountability for adequate staffing and the DON will assess staffing needs related to census and acuity.

1b. The hospital failed to provide any other policies related to nurse staffing at the time of the survey.

1c. During an interview on 09/09/20 at 3:15 PM, Staff B, Regional DON, Registered Nurse (RN) stated the hospital policy regarding staffing includes staffing with a minimum of one RN on site during each shift and she further stated it is a regulatory requirement. She then stated an RN is always available by phone if not actually on site and the previous DON who left in July lived five minutes from the Hospital. When a shift did not have an RN scheduled to cover, the DON would be available to come to the Hospital if she were needed. She then stated that was not a common practice and occasionally with late call ins by scheduled staff it was not possible to replace them immediately especially if staff from the previous shift were unable to stay over for the next shift. She further stated there could be lapses in the staffing on a shift until an RN was able to come in to fill the void. Licensed Practical Nurses (LPN) are not to staff a shift without an RN for oversight and she clarified there should never be a reason a staff member would work without clocking in on the time clock.

1d. During an interview on 08/25/20 at 1:00 PM, Staff Q, RN stated that night staffing is "usually" two nurses and two mental health assistants.


2a. Review of a hospital policy titled, "Fall Prevention Protocol" revised 03/01/20 showed: POLICY: All hospitalized patients are considered a fall risk and will be assessed to minimize their risk of falling. St. Anthony's Senior Care Hospital staff will work to actively reduce the risk of falls by ensuring a safe physical environment and appropriate identification of patients at risk for falls.

2b. PROCEDURE: ENVIRONMENTAL AND HOSPITAL SAFETY. All hospital staff are responsible for reducing fall risks and ensuring a safe environment free from hazards. All clinical and non-clinical staff are aware of high fall risk patients and will work within their scope of practice to prevent patient falls. Staff work as a cohesive team to eliminate hazards, by involving Environmental Services and Engineering as appropriate ...


3a. The hospital failed to provide a policy and procedure regarding the practice of placing patients on mattresses in the commons area to provide nursing staff easier observation of patients at risk for falls, who are demonstrating behaviors which place them at higher risk for falls, including obtaining a physician's order. Even though the hospital did not have a policy directing nursing staff to obtain a physician's order, it was a common and widespread understanding of the nursing staff that a physician's order was required to place these patients on mattresses in the commons room.

3b. During an interview on 08/24/20 at 8:30 AM, Staff B, Regional DON stated all direct patient care staff are responsible for performing environmental checks on every patient every 15 minutes, noting their location and activity. She confirmed mattresses are placed on the floor at night in the commons area for any patient who is assessed as a high fall risk and tends to get up unassisted or wander. She stated that placing the mattress on the floor helps reduce the risk of falls.

3c. During an interview on 08/25/20 at 1:00 PM, Staff Q, RN stated she voiced concern about the practice of patients sleeping on mattresses on the floor in the commons area and was told Staff Y, Psychiatrist "believes it to be safe practice to reduce the fall risks for patients and allows patients to be watched by staff." She then stated, "if I were working nights and it came down to patient safety I would consider putting a patient on the floor to avoid risking a fall, however I would make sure there is an order for it."

3d. During an interview on 08/24/20 at 3:20 PM Staff H, LPN stated that high fall risk patients are occasionally placed on a mattress on the floor in the commons area. A physician order is obtained. She stated, "the patient is on the floor for their safety."

3e. During an interview on 08/26/20 at 1:15 PM, Physician Staff Z, Hospitalist, stated that the hospital does not have enough staff to provide one on one observation always and with the senior psychiatric patient, a continuous higher level of observation is required. Staff Z, stated further, "the mortality rate of death following a fall in the frail elderly is much more of a concern than a fire safety issue or patient's dignity."

3f. During an interview on 08/26/20 at 9:10 AM, Staff Y, Psychiatrist, stated that he was aware some patients are placed on mattresses on the floor to sleep at night, but that is because they are a high fall risk and having them on the floor in the commons area allows for a staff member to keep an eye on them. He further stated that he does not give an order authorizing the patient to sleep on the floor, but nursing staff do notify him when a patient sleeps on the floor. He further stated the nursing staff brought the option to him as an opportunity to prevent falls.

3g. During an interview on 08/24/20 at 4:30 PM, Staff B, Regional Director of Nursing (DON) stated that after the hospital opened there was a high percentage of patient falls even with 15-minute checks. The nurses met with the DON at the time and Staff Y, Psychiatrist with an agreement between all staff and the psychiatrist to move mattresses onto the floor in the commons area if a high fall risk patient was not redirectable. She stated previously, the hospital attempted to place mattresses on the floor next to the bed, but the patients could not be continuously monitored. She clarified a physician order is required prior to placing the mattress on the floor.


4a. Review of Patient 1's medical record on showed an admission of 07/15/20 through 08/07/20. His admitting diagnosis was hallucinations, delusions, obsessive compulsive disorder (OCD), anxiety, harm to others, self-care deficit, and [DIAGNOSES REDACTED] (the second most common type of progressive dementia after Alzheimer's disease dementia and causes a progressive decline in mental abilities). Medical complications included hypertension (high blood pressure) and coronary artery disease (CAD) (blockage of major blood vessel).

4b. The admission nursing assessment performed by Staff P, Registered Nurse (RN) on 07/15/20 showed his Morse fall score at 75, placing him at high fall risk and he had an unstable ambulation requiring ambulation with a wheelchair. Further fall risk documentation from 07/17/20 through 08/05/20 showed his score alternating from a low risk score of 25 to a high-risk score of 75. Review of the nursing notes showed he fell on [DATE] at 8:20 PM, 07/21/20 at 6:00 PM, 07/25/20 at 6:00 PM.

4c. The Initial Safety Treatment Plan dated 07/15/20 showed Patient 1 experienced chronic confusion, hallucinations, frequent attempts to get out of bed, and was exit seeking.

4d. Review of the Nursing note narratives showed he was sleeping on a mattress on the floor in the commons area per physician orders on 07/15/20 at 8:30 PM.

4e. However, the medical record lacked documented evidence of a signed physician's order to place the mattress on the floor in the commons area.

4f. Review of the document titled, "Detailed Hours Overview," showed staff who worked the night shift on 07/15/20 from 6:00 PM to 6:00 AM. The staff working on 07/15/20 from 6:00 PM to 10:00 PM included: one RN , one CNA, one Mental Health Tech (MHT) and a Universal Worker (UW). Staff working on 07/15/20 from 10:00 PM to 6:00 AM included: one RN, one CNA, and one Mental Health Tech (MHT). The census for the night shift on 07/15/20 was 13 patients. The hospital failed to have two nurses working on this shift as required per the hospital staffing guideline.

Documentation showed that Patient 1 slept on a mattress in the commons area on 07/15/20, a night that hospital staffing did not meet the minimum requirement to have two nurses in the hospital every shift .



5a. Review of Patient 2's medical record showed an admission of 08/06/20 to present. Her admitting diagnosis was depression, anxiety, harm to others, exit seeking, and dementia (loses the ability to think, remember, learn, make decisions, and solve problems). Symptoms may also include personality changes and emotional problems). Medical complications included hypertension, chronic obstructive pulmonary disease (COPD) (lung disease causing permanent lung damage), diabetes, and [DIAGNOSES REDACTED] (low [DIAGNOSES REDACTED]).

5b. The admission nursing assessment performed by Staff B, RN, Director of Nursing (DON) on 08/06/20 documented her Morse fall scale assessment at 75, placing her at high risk for falls. Further nursing documentation from 08/06/20 through 08/21/20 showed no evidence of nursing assessments performed with an assigned fall risk score. Further documentation showed Patient 2 fell in the bathroom on 08/11/20 at 1:45 AM with no resulting injury.

5c. Review of nursing note narratives showed Patient 2 was sleeping on a mattress on the floor in the commons area on the following dates and times:

1. 08/14/20 at 10:00 PM
2. 08/15/20 at 10:00 PM
3. 08/16/20 at 12:00 AM and 4:00 AM
4. 08/17/20 at 4:00 AM
5. 08/18/20 at 4:00 AM, 6:00 AM and 10:00 PM
6. 08/19/20 at 2:00 AM, 4:00 AM and 6:00 AM

5d. The medical record lacked documented evidence of a signed physician order to place the mattress on the floor in the commons area for any of these dates.

5e. Review of the document titled, "Detailed Hours Overview," showed nursing staff variances for three of the six night shifts (6:00 PM to 6:00 AM) Patient 2 slept on a mattress in the commons room.

1. 08/15/20 there was two RNs and one CNA clocked in for the 6:00 PM to 6:00 AM shift. The hospital did not provide patient census for this date.

The hospital failed to maintain its "usual" staffing level of two nurses and two techs, CNAs, and/or universal workers working night shift.

2. 08/16/20 there was two RNs and one CNA clocked in for the 6:00 PM to 6:00 AM shift. The hospital did not provide patient census for this date.

The hospital failed to maintain its "usual" staffing level of two nurses and two techs, CNAs, and/or universal workers working night shift.

3. 08/17/20 there were two LPNs and two CNAs clocked in for the 6:00 PM to 6:00 AM shift. The patient census was 14 on this date.

The hospital failed to meet federal regulations to have an RN working every shift and failed to have an RN working every shift per the hospital's "Staffing Guideline."



6a. Review of Patient 3's medical record showed an admission from 07/16/20 through 08/21/20. His admitting diagnosis was harm to others, unspecified dementia, delusional disorder, adjustment disorder with depressed mood and anxiety, and generalized anxiety disorder. Medical complications included COPD, spinal stenosis, (abnormal narrowing of the spine placing pressure on spinal cord and nerve roots), benign prostate hyperplasia (BPH) (enlarged prostate gland), and Parkinson's disease (long term degenerative disorder of the central nervous system affecting the motor system).

6b. The admission nursing assessment performed by Staff Q, RN on 07/16/20 documented a Morse fall risk score of 115, placing him at high fall risk noting he was very weak requiring full assist with transfers. Additional nursing assessments on 07/23/20 showed a fall risk score of 40, moderate fall risk, and a score of 75, high fall risk on 07/24/20.

6c. The Initial Safety Treatment Plan dated 07/16/20 included fall risk due to impulsivity and fall risk score of 115, Goal - Decreased falls by following interventions daily for 14 days. Intervention - Nursing to assess fall risk every shift, mattress on the floor to decrease falls, close observation while awake to decrease falls, use a wheelchair for ambulation to decrease falls.

6d. Further documentation in the medical record showed evidence that Patient 3 fell , hitting his head, on 07/18/20 at approximately 2:00 AM. Review of the document titled, "Detailed Hours Overview," showed staffing levels were below the "usual" staffing level on this night shift. There were two RNs and only one CNA on staff at the time of this fall. The "ususal" staffing level for night shift included two nurses (with at least one RN) and a combination of two mental health technicians, and/or CNAs, and/or universal workers.

6e. Further documentation in the medical record showed evidence Patient 3 fell four additional times during his admission. Patient 3 fell on [DATE] at 8:30 AM with no injury and again on 07/25/20 at 2:30 PM with no injury. Review of the nursing note narratives below showed that nursing staff documented Patient 3 was sleeping on a mattress on the floor in the commons area on the day shift 07/25/20 following his falls that day at 4:00 PM and 6:00 PM and the next morning on 07/26/20 at 4:00 AM. Then, Patient 3 fell on [DATE] at 10:00 AM with no injury. Review of the nursing note narratives below showed that nursing staff documented Patient 3 was sleeping on a mattress on the floor on 08/09/20 at 10:00 PM in the commons area on the night shift following his fall that day at 10:00 AM and on 08/10/20 at 12:00 AM, 8:00 PM, and 10:00 PM. Finally, Patient 3 fell on [DATE] at 1:49 PM with no injury. Review of the nursing note narratives below showed that nursing staff documented Patient 3 was sleeping on a mattress on the floor on 08/11/20 at 2:00 AM, 4:00 AM, 6:00 AM, 10:00 PM, and 08/12/20 at 4:00 AM and 6:00 AM.


6f. Review of nursing note narratives showed Patient 3 was sleeping on a mattress on the floor in the commons area, 22 of 37 days/nights during his hospital stay, on the following dates and times:

1. 07/16/20 at 6:30 PM
2. 07/17/20 at 7:20 PM
3. 07/18/20 at 4:45 AM
4. 07/19/20 at 6:00 AM
5. 07/20/20 at 6:00 AM
6. 07/23/20 at 12:00 AM
7. 07/24/20 at 12:00 AM
8. 07/25/20 at 4:00 PM and 6:00 PM
9. 07/26/20 at 4:00 AM
10. 07/28/20 at 6:00 PM
11. 08/01/20 at 4:00 AM, 6:15 AM, 8:00 AM and 10:00 PM
12. 08/02/20 at 12:00 AM, 4:00 AM, 6:00 AM and 10:00 PM
13. 08/06/20 at 2:00 PM and 10:00 PM
14. 08/07/20 at 12:00 AM, 8:00 AM and 9:55 PM
15. 08/09/20 at 10:00 PM
16. 08/10/20 at 12:00 AM, 8:00 PM and 10:00 PM
17. 08/11/20 at 2:00 AM, 4:00 AM, 6:00 AM, and 10:00 PM
18. 08/12/20 at 4:00 AM and 10:00 PM
19. 08/13/20 at 12:00 AM, 2:00 AM and 4:00 AM
20. 08/16/20 at 10:00 PM
21. 08/17/20 at 10:00 PM and
22. 08/18/20 at 2:00 AM, 4:00 AM and 6:00 AM

6g. The medical record lacked documented evidence of a signed physician order to place Patient 3 on a mattress on the floor in the commons area for any of these dates.

6h. Review of the document titled, "Detailed Hours Overview," showed nursing staff variances for seven of the 22 night shifts (6:00 PM to 6:00 AM) Patient 3 slept on a mattress in the commons room.

1. 07/18/20 there were two RNs, one CNA, and one UW until 7:00 PM; the hospital did not have a second CNA scheduled beyond 7:00PM. The hospital did not provide patient census for this date.

The hospital failed to maintain its "usual" staffing level of two nurses and two techs, CNAs, and/or universal workers working night shift.

2. 07/19/20, one RN clocked out at 2:37 AM on 07/20/19, one MHT and one UW worked 11:00 AM to 7:00 PM. The hospital did not provide patient census for this date.

The hospital failed to have evidence that an RN or LPN was in the hospital after 2:37 AM on 07/20/19, until one LPN clocked in at 5:56 AM and a second one (LPN) clocked in at 6:00 AM.

The hospital failed to meet the minimum requirement to have two nursing staff working on every shift per the hospital's "Staffing Guideline" and failed to meet federal regulations to have an RN working every shift and failed to meet their staffing policy requirements to have an RN working every shift.

3. 07/20/20 there was one RN and two CNAs clocked in for the 6:00 PM to 6:00 AM shift. The patient census was 14 on this date.

The hospital failed to meet the minimum requirement to have two nursing staff working on every shift per the hospital's "Staffing Guideline."

4. 07/24/20 there were two LPNs and one CNA clocked in for the 6:00 PM to 6:00 AM shift. The patient census was 13 on this date.

The hospital failed to meet federal regulations to have an RN working every shift and failed to have an RN working every shift per the hospital's "Staffing Guideline". The hospital failed to maintain its "usual" staffing levels to have two nurses (including one RN) and two techs, CNAs, and/or universal working night shift.

5. 08/13/20 there was one RN and four CNAs clocked in for the 6:00 PM to 6:00 AM shift. The patient census was 13 on this date.

The hospital failed to have two nurses working every shift per the hospital's "Staffing Guideline".

6. 08/15/20 and 08/16/20 there was two RNs and one CNA clocked in for the 6:00 PM to 6:00 AM shift. The hospital did not provide patient census for 08/15/20 or 08/16/20.

The hospital failed to maintain its "usual" staffing level of two nurses and two techs, CNAs, and/or universal workers working night shift.

7. 08/17/20 there were two LPNs and two CNAs clocked in for the 6:00 PM to 6:00 AM shift. The patient census was 14 on this date.

The hospital failed to meet federal regulations to have an RN working every shift and failed to have an RN working every shift per the hospital's "Staffing Guideline."



7. Review of hospital documents titled, "Detailed Hours Overview" dated 07/01/20 through 07/25/20 and 08/09/20 through 08/22/20 showed there was not a Registered Nurse (RN) clocked in to work on the following shifts:

1. 07/03/20, 6:00 PM to 6:00 AM, the document showed Staff S, LPN; Staff FF, Mental Health Technician (MHT); Staff GG, CNA; and Staff HH, Universal Worker (UW) clocked in to work during this shift.

2. 07/13/20, 6:00 PM to 6:00 AM, the document showed: Staff R, LPN; Staff FF, MHT; and Staff X, CNA/LPN, clocked in to work during this shift.

3. 07/24/20, 6:00 PM to 6:00 AM, the document showed: Staff R, LPN; Staff EE, LPN; and Staff GG, CNA, clocked in to work during this shift.

5. 08/17/20, 6:00 PM to 6:00 AM, the document showed: Staff S, LPN; Staff X, LPN; Staff DD, CNA; and Staff GG, CNA clocked in to work during this shift.

6. 08/21/20, 6:00 PM to 6:00 AM, the document showed, Staff S, LPN; Staff X, LPN; and Staff DD, CNA, clocked in to work during this shift.

7. 08/22/20, 6:00 PM to 6:00 AM, the document showed: Staff S, LPN; Staff X, LPN; Staff DD, CNA; and Staff FF, CNA clocked in to work during this shift.

The hospital failed to meet federal regulations to have an RN working every shift and failed to have an RN working every shift per the hospital's "Staffing Guideline."



8. Review of hospital documents titled, "Daily Census Sheet" and "Detailed Hours Overview" from 07/01/20 through 07/25/20 and 08/09/20 through 08/22/20 showed the following census and staffing pattern for the 6:00 PM to 6:00 AM shift that did not have two nurses staffed the entire shifts:

1. 07/01/20 - Patient census of 17 and staffing showed Staff J, RN; Staff FF, MHT; and Staff HH Universal Worker (UW), who worked 6:00 PM to 10:00 PM. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

2. 07/03/20 Patient census of 13 and staffing showed, Staff S, LPN; Staff FF, MHT; Staff GG, CNA; and Staff HH, UW were clocked in to work during this shift. The hospital did not have an RN scheduled this shift which is a regulatory and hospital policy requirement and the hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

3. 07/11/20 The hospital did not provide the census and staffing showed Staff J, RN; and Staff GG, CNA. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

4. 07/12/20 The hospital did not provide the census and staffing showed Staff J, RN; Staff GG CNA and Staff HH UW worked from 11:00 AM to 7:00 PM. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

5. 07/13/20 Patient census of 13 and staffing showed Staff R, LPN; Staff FF, MHT; and Staff X, CNA/LPN, were clocked in to work during this shift. The hospital did not have an RN scheduled this shift which is a regulatory and hospital policy requirement.

6. 07/15/20 Patient census of 13 and staffing showed Staff J, RN; Staff FF, MHT; Staff GG, CNA; and Staff HH, UW worked from 6:00 PM to 10;00 PM. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement and the hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

7. 07/19/20 The hospital did not provide the census and staffing showed Staff J, RN clocked out at 2:37 AM, Staff FF, MHT; and Staff HH, UW, worked from 11:00 AM until 7:00 PM. There were no other RNs or LPN's clocked in after 2:37 AM, The hospital did not have an RN scheduled the remainder of this shift which is a regulatory and hospital policy requirement and the hospital did not have a second nurse scheduled for the entire shift which is a hospital policy requirement.

8. 07/20/20 Patient census of 14 and staffing showed Staff J, RN; Staff S, LPN worked from 6:00 AM until 11:00 PM; Staff X, worked as a CNA; and Staff GG, CNA. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

9. 07/21/20 Patient census of 13 and staffing showed Staff J, RN; Staff FF, MHT; and Staff X, CNA. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.

10. 08/13/20 Patient census of 13 and staffing showed Staff J, RN; Staff CC, CNA; Staff FF, MHT; and Staff GG, CNA. The hospital did not have a second nurse scheduled this shift which is a hospital policy requirement.
VIOLATION: RN/LPN STAFFING Tag No: A0393
Based on interview and document review, the hospital failed to ensure a registered nurse (RN) was on duty and immediately available to patients and patient care staff at all times and failed to ensure two nurses were in the hospital every shift as directed by policy. Failure by the hospital to always have an RN on site placed all patients at risk of care provided by unsupervised, unqualified, and untrained staff.


Findings Include:

1a. Review of a hospital policy titled, "Staffing Guidelines", with an original date of 03/26/18, and revised 08/27/20, showed the staffing pattern will ensure the availability of a Registered Nurse 24 hours per day and a minimum of two nurses will be in the hospital every shift with the Director of Nursing (DON) or designee available 24/7 on call availability. The policy further showed the DON or designee maintains the 24-hour accountability for adequate staffing and the DON will assess staffing needs related to census and acuity.

1b. The hospital failed to provide any other policies related to nurse staffing at the time of the survey.


2a. Review of a hospital document titled, "Detailed Hours Overview" showed the following staff working 6:00 PM to 6:00 AM with exceptions noted:

1. 07/03/20, Staff S, LPN; Staff FF, MHT; Staff GG, certified nurse assistant (CNA); and Staff HH, UW. Documentation lacked evidence that an RN was present. Patient census was 13.

2. 07/12/20, Staff J, RN; Staff GG, CNA; and Staff HH, UW worked 11:00 AM to 7:00 PM. Documentation lacked evidence that a second nurse present. The hospital did not provide the census information for 07/12/20.

3. 07/13/20, Staff R, LPN; Staff FF, MHT; Staff X, CNA. There was no documented evidence that an RN was present. Patient census was 13.

4. 07/19/20, Staff J, RN clocked out at 2:37 AM on 07/20/19. Staff FF, MHT and Staff HH, UW worked 11:00 AM until 7:00 PM. There was no documented evidence that an RN or LPN was in the hospital after 2:37 AM on 07/20/19, until Staff S, LPN clocked in at 5:56 AM and Staff H, LPN clocked in at 6:00 AM. The hospital did not provide the census information for 07/19/20.

5. 07/24/20 two LPNs and one CNA worked. There was no documented evidence that an RN was present. The hospital did not provide the census information for 07/24/20.

6. 08/17/20 from 6:00 PM to 6:00 AM, two LPNs and two CNAs worked. There was no documented evidence that an RN was present. Patient census was 14.

The Hospital did not provide the "Daily Census Sheets" for any Saturdays or Sundays for the timeframe of 07/01/20 to 08/28/20.


3. During an interview on 09/09/20 at 3:15 PM, Staff B, Regional DON, Registered Nurse (RN) stated the hospital policy regarding staffing includes staffing with a minimum of one RN on site during each shift and she further stated it is a regulatory requirement. She then stated an RN is always available by phone if not actually on site and the previous DON who left in July lived five minutes from the Hospital. When a shift did not have an RN scheduled to cover, the DON would be available to come to the Hospital if she were needed. She then stated that was not a common practice and occasionally with late call ins by scheduled staff it was not possible to replace them immediately especially if staff from the previous shift were unable to stay over for the next shift. She further stated there could be lapses in the staffing on a shift until an RN was able to come in to fill the void. Licensed Practical Nurses (LPN) are not to staff a shift without an RN for oversight and she clarified there should never be a reason a staff member would work without clocking in on the time clock.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, staff interview and Life Safety Code complaint investigation (KS 441; ASPEN #ON9D21), the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to ensure that all means of egress are free of all obstructions or impediments and failed to adequately protect the patients in this facility by allowing for certain patients to sleep in an open area and not within a sleeping suite. This deficient practice could impede patients and staff from safely exiting one of one smoke zone area, including the dining room and common area, during a fire emergency situation, placing them at risk for injury and even death.

Findings Include:

Review of the LSC complaint investigation results dated 08/26/20 revealed that hospital staff were moving mattresses out of patient rooms at various times during the daytime and nighttime hours into the commons area (open area shared by all patients for dining and activities; staff in the nursing station can view patients in the area). Hospital staff placed patients, who are assessed as at risk for falls and that try to get out of their beds on their own or have behaviors that make them difficult to redirect, are moved into the commons area to sleep on a mattress on the floor. The hospital staff moved the mattresses out of patient rooms at various times during the daytime and nighttime hours into the commons area for patients to sleep, preventing the patients from being protected by noncombustible or limited combustible construction with a fire rated door.

This deficient practice resulted in the LSC inspector of the state fire marshal's office notifying the hospital's administration that the Centers for Medicare and Medicaid Services (CMS) identified this as an Immediate Jeopardy (IJ), (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) on 08/26/20 around 4:10 PM. The hospital removed the LSC immediate jeopardy on 08/27/20 at 4:30 PM by submitting a credible plan of removal that included the following:

1. Verbal Agreement that mattresses would no longer be put on the floor or in common area (onsite 08/26/20).
2. Revised Fall Policy 1044 - specifically addressing issues raised in K211 and K255 of the LSC 2567.
3. Use of alternative interventions for our fall risk patients.
4. All staff education provided weekly. Immediate staff education provided at shift change 08/26/2020 regarding no longer using mattresses on the floor in common area or inpatient rooms.
5. The Environment of Care Director's Rounding tool will document compliance of not having mattresses in the common area.
6. Action plan to be included in our QAPI program.
7. Action Plan and resulting policies will be provided to Medical Executive Committee and Governing Board for final ratification.
8. All compliance, education and documentation will be provided to Environment of Care/QAPI/
MEC meetings.

(Refer to A-0709 and LSC 2567 ASPEN #ON9D21 for further details).
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
Based on document review, record review, interview and Life Safety Code complaint investigation findings (KS 441; ASPEN #ON9D21), the hospital failed to meet the applicable provisions of the current Life Safety Code (LSC) when they failed to ensure that all means of egress are free of all obstructions or impediments by placing mattress on the floor of the commons area (open area shared by all patients for dining and activities; staff in the nursing station can view patients in the area) and failed to adequately protect the patients in the facility by allowing for patients assessed as fall risks, to sleep in an open area and not within a sleeping suite, for 3 of 4 patients reviewed (Patients 1, 2, and 3). This deficient practice has the potential to impede patients and staff from safely exiting one of one smoke zone area, including the dining room and common area, during a fire emergency situation, placing them at risk for injury and even death.

Findings Include:

1. The hospital staff moved mattresses out of patient rooms at various times during the daytime and nighttime hours into the common area for patients to sleep preventing the patients from being protected by noncombustible or limited combustible construction with a fire rated door.

2. It was confirmed through record review that Patients 1, 2 and 3, who are assessed as at risk for falls and who try to get out of their beds on their own and who demonstrate a difficulty for staff to redirect, are moved into the commons area to sleep on a mattress on the floor. (Refer to A-392 for further details).

3. During interviews on 08/25/20 and 08/26/20, staff confirmed that moving the residents to the floor was due to fall risk. Staff indicated that this practice had been occurring anywhere from 6 months up to 2 years. All staff confirmed that mattresses are being moved out to the commons area during the night and occasionally during the day. (Refer to A-392 for further details).

4. The mattresses obstruct the egress (exit) pathway in the case of an emergency, mattresses in spaces open to the egress corridor could create a tripping hazards in the egress path, subjecting patients and staff to smoke inhalation, and injury or death from extreme heat and fire in the event of a fire emergency.

5. During an interview on 08/26/20 at 9:55 AM, Staff A, Chief Executive Officer (CEO), stated that patient safety was top priority at this hospital. He stated that on occasion the hospital has patients who have difficulty in sleeping for multiple reasons, are agitated or just feel like being on the floor. He stated that patients while in their rooms are checked on every 15 minutes. When the patients try to get out of bed by themselves they run a high risk of falling. Occasionally the nurses move the patient's mattress off their bed and out into the commons area to allow them to sleep there and nursing staff can monitor them to make sure they don't try to get up by themselves and fall. Staff A, stated that the mattresses were placed on either side of the TV against the wall. He further stated that he had never known about more than two patients at a time. He stressed that the safety of the patient was top priority even above fire. He noted that sometimes they place patients on the mattress's during the daytime hours in the commons area. He could not confirm how long this practice has been in place.