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.

STRATEGIC BEHAVORIAL CENTER-GARNER 3200 WATERFIELD DRIVE GARNER, NC 27529 Oct. 16, 2020
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, internal investigation review, observation, and staff and provider interviews, facility staff failed to provide care in a safe setting by failing to ensure geriatric behavioral health patients were assessed for fall risk and interventions were put in place to minimize the risk of falls and injury for 6 of 10 sampled patients at high risk of falls (#7; #3; #18; #19; #6; #17).

The findings include:

Review of the hospital policy titled "Edmonson Fall Reduction Assessment Policy," with revision date of 03/25/2020, revealed "Policy: Patient Safety is an ongoing responsibility of all staff. In order to reduce the risk of patient injuries as a result of a fall, the staff will assess and reassess the patient's level of risk for falls and in conjunction with the treatment team, institute appropriate interventions through the following procedures. ... Definition: A fall is defined as an event that results in the patient or any part of the patient's body coming to rest inadvertently on the floor or other surface lower than the patient's body. Purpose: To prevent falls and to limit injury from falling when it does occur. Procedure: The Edmonson Fall Risk Assessment will be completed by a Registered Nurse during the intake phase of admission. ... 1. Each patient will be reassessed each shift. 2. Reassessment must also be completed if there is a significant change in the patient's mental status or physical condition. ... 2. Patients with a score of 90 or greater will be classified as a Higher Risk for falls. 3. The Fall Prevention measures for patients at high risk must be implemented and appropriate equipment utilized by staff as indicated, for the patient's safety. ... C. Patients who score 90 or greater will be placed on the following precautions: a. Yellow ID Band b. Yellow non-skid socks b. High Risk--Patient will have: a. Yellow ID Band b. Yellow non-skid socks c. Yellow locator d. Fall Mat e. Magnetic Falling Star outside of patient's room f. Fall re-assessment every shift. ... IN THE EVENT OF A PATIENT FALL, WITH OR WITHOUT INJURY 1. The staff member discovering the fall will attend to the patient's immediate needs: a. A nurse will assess the patient immediately b. The attending physician will be promptly notified to determine the need for further evaluation ... e. Neurological checks and vital signs as ordered or appropriate for injury .. .i. Patient's fall risk will be reassess (sic) ... immediately after the fall ..."

1. Review of a closed medical record for Patient #7 revealed an [AGE] year old male with a history of dementia, TBI (traumatic brain injury) and CVA (cerebrovascular accident or stroke) was admitted on [DATE] at 1545 for evaluation of suicidal ideation. Review of the record revealed there was not an Edmonson Psychiatric Fall Risk Assessment documented from 09/24/2020 through 10/13/2020 (20 days); therefore, no documentation of a falls risk score was documented. Review revealed Patient #7 fell on [DATE] at 1830 and had an assisted fall on 09/28/2020 at 0345. Patient #7 was discharged to an ALF (assisted living facility) on 10/13/2020.

Review of an incident report for Patient #7 completed by RN #5 on 09/26/2020 at 1947 revealed the second fall was observed; however, no interventions were in place at the time of the fall.

Review of a signed statement from RN #9 dated 09/28/2020 revealed "MHT (Mental Health Technician) #14 who was sitting with Pt (sic), as LOSWA (line of sight while awake) reported that Pt. (sic) got up from his bed and was trying to ambulate but unable to, (sic) as he was going to fall, (sic) the MHT in the room with him lowered him to the floor to sit on his bottom. Writer was called in, (sic) pt. was assessed, (sic) No injuries noted, (sic) pt (sic) started crawling after he was assisted to the floor. NP on call notified, AOC notified (sic), family called no answer and voicemail left."

Interview on 10/14/2020 at 1111 with LPN #3 revealed the 900 Geriatric Behavioral Health Unit "does not utilize yellow stars on the patient doors to indicate a high risk for falls nor do they keep yellow armbands on the unit."

Interview on 10/14/2020 at 1443 with 900 Unit RN #5 revealed the yellow armbands are placed on falls risk patients during the admission process after the RN completed his/her assessment. Interview revealed she personally has never placed a yellow armband on a patient. Interview further revealed yellow nonskid socks are available throughout the facility and indicated a patient is a falls risk.

Interview on 10/14/2020 at 1618 with RN #9 revealed she "thinks day shift nurses complete falls risk shift assessments because patients are up during that shift". Interview further revealed RN #9 did not apply yellow armbands to patients and "thinks" the armbands are applied during the admission process.

Interview on 10/13/2020 at 1518 with RN #11 revealed a falls risk assessment should be completed daily. Interview further revealed the unit did not utilize stars outside of patient rooms. Interview revealed no falls risk assessment was documented on Patient #7 after his admission and prior to falling on 09/26/2020.

Interview with Director of Quality, Compliance and Risk Management on 10/15/2020 at 1408 revealed falls have been trending upward since May 2020. Interview revealed a Performance Improvement committee meeting was scheduled for Friday, 10/09/2020; however, was postponed. Interview revealed the goal is to have a meeting scheduled the week of 10/19/2020. Interview revealed the goal is to provide one to one coaching with LPN's (Licensed Practical Nurses) and CNA's regarding level of observations. Interview revealed the goal is to maintain consistency with staff so they can develop a rapport with patients. Interview revealed when hiring new staff facility will review qualifications to verify applicants are qualified to work with patients who are medically compromised. Interview revealed there was no falls risk assessment found in Patient #7's medical record.





2. Review of an open medical record for Patient #3 revealed the patient was transferred to and admitted on [DATE] at 1007 as Involuntary status with Unspecified Mood Disorder with homicidal ideations towards a family member. Review of nursing notes written by RN #17 dated 07/12/2020 at 0738 revealed "Pt. (Patient) was walking to his room, with walker when suddenly fell to the floor with (sic) his back. Pt hit his head. Pt was assisted to a chair. His vitals were BP (blood pressure) 167/77. O2 (oxygen) 96% (amount of oxygen in the blood), P (pulse) 96, Temp. (temperature) 97.3. No apparent injury but a small skin tear to the left thump (sic). Pt denies pain at time of fall. Said he was doing OK. Dr. notified and wife told of incident at 2000. Pt was able to talk with wife for along time. Continue to monitor for safety." Review of an Edmonson Psychiatric fall risk assessment on admission of 07/07/2020 revealed a score of 66, indicating low risk for falls. Review of an Edmonson psychiatric fall Risk assessment failed to reveal documentation of the fall risk assessment after the fall on 07/12/2020. Review of the falls risk assessment revealed the documentation of a falls risk assessment on 07/16/2020 (4 days after the fall). Review of orders written by NP #1 dated 07/12/2020 at 1215 revealed "CSpine + KUB (abdominal xrays covering the kidneys, ureters and bladder) 2 views xray s/p (status post) fall. 2. Neuro (symbols showing check) 24 hr 3. Motrin 600 mg po BID x 7 days (Anti inflammatory by mouth twice daily for 7 days). Ice to head/neck." Review of the results of the x-ray of the abdomen dated 07/12/2020 at 6:16 PM revealed "...Nonobstructive bowel gas pattern." Review of the results of the Cervical Spine 2 or 3 views dated 07/12/2020 at 6:18 PM revealed "...Limited radiographic evaluation of the cervical spine without gross evidence of fracture...." Review of a nurses note for Patient #3 written by the CNO dated 07/16/2020 at 0954 (4 days after the first fall) revealed "...@ 0930 resident found by staff sitting on bathroom floor. Resident states that he slipped. Resident states that he hit his head. (Physician group) notified, treatment plan in effect. Will continue to monitor for any changes." Review of orders written by NP #1 dated 07/16/2020 at 1445 revealed "1. Abdomen 2 views. 2. C-Spine xray 3. Lt (left) thumb xray. s/p (status post) fall. 4. Neuro (symbol for check) hourly x 12 hours."

Interview with RN #17 was not obtained because RN #17 was no longer employed at the facility.

Interview on 10/13/2020 at 1515 with the CNO revealed the first documentation of a falls risk assessment after the fall on on 07/12/2020 was recorded on 07/16/2020 (4 days after the fist fall). Interview revealed the facility staff failed to follow the falls policy for immediate reassessment of falls risk after a fall.

3. Observation on 10/16/2020 at 1000 through 1040 of the geriatric behavioral health unit revealed Patient #18 was sitting at a table with no yellow arm band or yellow socks. Observation revealed no star on Patient #18's room.

Review of a physician's History and Physical dated 09/19/2020 at 1425 revealed Patient #18, a [AGE] year old male, was admitted on [DATE] for dementia. Review of the falls assessment revealed a score of above 90 (high risk) for 09/30/2020 through 10/12/2020 (high risk falls). Review revealed no documentation for falls scores on 10/02/2020, 10/03/2020 and 10/09/2020 (3 days). Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift.

Interview on 10/16/2020 at 1040 with CNA #16, who had been employed for one month, revealed all patients with a falls risk score of 85 or higher is a high risk for falls. Interview revealed CNA #16 has not seen any stars on patient doors in the past month. Interview revealed the falls stickers (silver) on the observation sheets indicate the patient is on falls precautions.

Interview on 10/16/2020 at 1050 with LPN #15 revealed all patients are discussed during end of shift report. Interview revealed the policy should be followed to reassess high risk patients every shift. Interviewed revealed there was no documentation of fall risk assessments for Patient #18 for 10/02/220, 10/03/2020 or 10/09/2020. Interview revealed fall risk assessments were not assessed and documented every shift according to policy. Interview revealed Patient #18 did not have a yellow arm band, or yellow non-skid sox on, or a falling star on the patient's room door. Interview revealed the facility falls policy was not followed.

4. Observation on 10/16/2020 at 1000 through 1040 of the geriatric behavioral health unit revealed Patient #19 was sitting at table with no yellow socks or no yellow armband. Observation revealed no star on the patient's room door.

Review of a History and Physical dated 08/29/2020 at 1700 revealed Patient #19, a [AGE] year old male, was admitted on [DATE] for dementia. Review of the falls assessment revealed a score of above 90 on 10/10/2020 through 10/12/2020 and 10/14/2020 and 10/15/2020. Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift.

Interview on 10/16/2020 at 1050 with LPN #15 revealed all patients are discussed during end of shift report. Interview revealed the policy should be followed to reassess high risk patients every shift. Interview revealed Patient #19 did not have a yellow arm band, or yellow non-skid sox on, or a falling star on the patient's room door. Interview revealed the facility falls policy was not followed.

Interview on 10/16/2020 at 1040 with CNA #16, who has been employed for one month, revealed all patients with a falls risk score of 85 or higher is a high risk for falls. Interview revealed CNA #16 has not seen any stars on patient doors in the past month.

5. Observation on 10/16/2020 at 1000 through 1045 of the geriatric behavioral health unit revealed Patient #6 was walking around the unit unattended. Observation revealed Patient #6 was not wearing a yellow arm band. Observation revealed no star on Patient #6's room door.

Review of a History and Physical dated 10/05/2020 at 1510 revealed Patient #6, a [AGE] year old female, admitted on [DATE] for Major Depressive disorder. Review of the falls risk scores beginning on 10/05/2020 through 10/16/2020 revealed scores above 90. Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift from 10/05/2020 through 10/12/2020 (12 days).

Interview on 10/16/2020 at 1050 with LPN #15 revealed all patients are discussed during the end of shift report. Interview revealed the policy should be followed to reassess high risk patients every shift. Interview revealed Patient #6 did not have a daily falls risk assessment, yellow arm band or falls star on the door.

6. Observation on 10/16/2020 at 1000 through 1045 of the geriatric behavioral health unit revealed Patient #17 sitting in a chair with no fall star on his room door.

Review of a History and Physical dated 10/14/2020 at 1915 revealed Patient #17, a [AGE] year old male, was admitted on [DATE] for schizophrenia. Review revealed a falls risk score of above 90 dated 10/14/2020 through 10/15/2020. Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift.

Interview on 10/16/2020 at 1040 with CNA #16, who has been employed for one month, revealed all patients with 85 or higher were a high risk for falls. Interview revealed CNA #16 has not seen any stars on patient doors in the past month.

In summary, nursing staff failed to ensure supervision and safety of the geriatric behavioral health patients by failing to follow the facility policy to assess patients' risk of falls and implement measures to prevent falls.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedures, observations, medical record reviews, quality committee minutes, and staff interviews, the facility staff failed to identify, develop an action plan for falls, and show sustained improvement upon review of the quality data collected on falls in the facility. Facility staff failed to implement falls precautions according to the facility policy for 4 of 7 observed geriatric patients that were identified as high falls risk (#18, #19, #6, #17).

The findings include:

Review on 10/16/2020 of the facility policy titled "PI Performance Improvement," revised 06/01/2016, revealed "...Policy: ...Efforts to measure quality will be conducted in a planned manner with specific expectations delineated for all improvement activities ...3. Priorities are also established for those improvement activities identified after initial measurement processes are completed. In response to the identification of a problem or opportunity, measurement of the extent of the problem or determination of baseline performance occurs from which an action plan is developed ... 4. Using a systematic and organized approach, improvement activities will be initiated one of two ways. They will start either through specific quality control measures designed to review effectiveness and build and maintain stability; or through improvement team activities designed to focus on specific issues or processes in development or in need of improvement ..."

Review of the hospital policy titled "Edmonson Fall Reduction Assessment Policy," with revision date of 03/25/2020, revealed "Policy: Patient Safety is an ongoing responsibility of all staff. In order to reduce the risk of patient injuries as a result of a fall, the staff will assess and reassess the patient's level of risk for falls and in conjunction with the treatment team, institute appropriate interventions through the following procedures. ... Definition: A fall is defined as an event that results in the patient or any part of the patient's body coming to rest inadvertently on the floor or other surface lower than the patient's body. Purpose: To prevent falls and to limit injury from falling when it does occur. Procedure: The Edmonson Fall Risk Assessment will be completed by a Registered Nurse during the intake phase of admission. ... 1. Each patient will be reassessed each shift. 2. Reassessment must also be completed if there is a significant change in the patient's mental status or physical condition. ... 2. Patients with a score of 90 or greater will be classified as a Higher Risk for falls. 3. The Fall Prevention measures for patients at high risk must be implemented and appropriate equipment utilized by staff as indicated, for the patient's safety. ... C. Patients who score 90 or greater will be placed on the following precautions: a. Yellow ID Band b. Yellow non-skid socks b. High Risk--Patient will have: a. Yellow ID Band b. Yellow non-skid socks c. Yellow locator d. Fall Mat e. Magnetic Falling Star outside of patient's room f. Fall re-assessment every shift. ..."

Review on 10/15/2020 of the Quality data with the Director of Quality, revealed falls that were observed, unobserved and assisted were aggregated, tracked and reported monthly to the Quality and Patient Safety Committees. Review revealed the falls data reported was 05/2020-7 falls with a threshold for action- 5 total falls; 06/2020-13 falls; 07/2020- 14 falls; and 08/2020- 18 falls. Review revealed, for the 05/2020 Quality Committee meeting, the action plan was "Ensure patients are being assessed per the Falls policy as warranted. CNO [Chief Nursing Officer] will provide additional education to nursing staff regarding monitoring of patients on falls precaution and ensuring property assessment of patients. The Patient Safety Committee will monitor any patients that has had 2 or more falls to ensure all precautions are in place." Review revealed, for the 07/2020; 08/2020; and 09/2020 Quality Committee meetings, the action plan was "Ensure patients are being assessed per the Falls policy as warranted. CNO [Chief Nursing Officer] will provide additional education to nursing staff regarding monitoring of patients on falls precaution and ensuring property assessment of patients. Pharmacy review of patients with multiple falls." Further review revealed no documentation provided of Patient Safety Committee minutes related to falls, training/education for staff related to falls, monitoring of patients with 2 or more falls, or pharmacy reviews from 05/2020 through 08/2020.

1. Observation on 10/16/2020 at 1000 through 1040 of the geriatric behavioral health unit revealed Patient #18 was sitting at a table with no yellow arm band or yellow socks. Observation revealed no star on Patient #18's room.

Review of an open medical record for Patient #18 revealed an [AGE] year old male admitted on [DATE] for dementia. Review of the falls risk assessment revealed a score of above 90 (high risk) for 09/30/2020 through 10/12/2020 (high risk falls). Review revealed no documentation for falls scores on 10/02/2020, 10/03/2020 and 10/09/2020 (3 days). Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift.

Interview on 10/16/2020 at 1040 with CNA #16, who had been employed for one month, revealed all patients with a falls risk score of 85 or higher is a high risk for falls. Interview revealed CNA #16 has not seen any stars on patient doors in the past month. Interview revealed the falls stickers (silver) on the observation sheets indicate the patient is on falls precautions.

Interview on 10/16/2020 at 1050 with LPN #15 revealed all patients are discussed during end of shift report. Interview revealed the policy should be followed to reassess high risk patients every shift. Interviewed revealed there was no documentation of fall risk assessments for Patient #18 for 10/02/220, 10/03/2020 or 10/09/2020. Interview revealed fall risk assessments were not assessed and documented every shift according to policy. Interview revealed Patient #18 did not have a yellow arm band, or yellow non-skid sox on, or a falling star on the patient's room door. Interview revealed the facility falls policy was not followed.

2. Observation on 10/16/2020 at 1000 through 1040 of the geriatric behavioral health unit revealed Patient #19 was sitting at table with no yellow socks or no yellow armband. Observation revealed no star on the patient's room door.

Review of an open medical record for Patient #19 revealed a [AGE] year old male admitted on [DATE] for dementia. Review of the falls assessment revealed a score of above 90 on 10/10/2020 through 10/12/2020 and 10/14/2020 and 10/15/2020. Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift.

Interview on 10/16/2020 at 1050 with LPN #15 revealed all patients are discussed during end of shift report. Interview revealed the policy should be followed to reassess high risk patients every shift. Interview revealed Patient #19 did not have a yellow arm band, or yellow non-skid sox on, or a falling star on the patient's room door. Interview revealed the facility falls policy was not followed.

Interview on 10/16/2020 at 1040 with CNA #16, who has been employed for one month, revealed all patients with a falls risk score of 85 or higher is a high risk for falls. Interview revealed CNA #16 has not seen any stars on patient doors in the past month.

3. Observation on 10/16/2020 at 1000 through 1045 of the geriatric behavioral health unit revealed Patient #6 was walking around the unit unattended. Observation revealed Patient #6 was not wearing a yellow arm band. Observation revealed no star on Patient #6's room door.

Review of an open medical record for Patient #6 revealed a [AGE] year old female admitted on [DATE] for Major Depressive disorder. Review of the falls risk scores beginning on 10/05/2020 through 10/16/2020 revealed scores above 90 (high risk falls). Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift from 10/05/2020 through 10/12/2020 (12 days).

Interview on 10/16/2020 at 1050 with LPN #15 revealed all patients are discussed during the end of shift report. Interview revealed the policy should be followed to reassess high risk patients every shift. Interview revealed Patient #6 did not have a daily falls risk assessment, yellow arm band or falls star on the door.

4. Observation on 10/16/2020 at 1000 through 1045 of the geriatric behavioral health unit revealed Patient #17 sitting in a chair with no fall star on his room door.

Review of an open medical record for Patient #17 revealed a [AGE] year old male admitted on [DATE] for schizophrenia. Review of a falls risk score of above 90 dated 10/14/2020 through 10/15/2020 (high falls risk). Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift.

Interview on 10/16/2020 at 1040 with CNA #16, who has been employed for one month, revealed all patients with 85 or higher were a high risk for falls. Interview revealed CNA #16 has not seen any stars on patient doors in the past month.

Interview on 10/15/2020 at 1405 with the Director of Quality, revealed falls had increased in the facility related to accepting patients with increased medical problems related to diagnoses and medications. Interview revealed falls within the facility was a "serious issue" and the rate of falls was "alarming." Interview revealed falls reported included observed, unobserved, and assisted but were not looked at individually. Interview revealed each unit was expected to provide real time education after a fall and review falls data and prevention, during their monthly nursing meetings. Interview revealed the real time education after a fall and the monthly nursing meetings were verbally ongoing and an "evolving process." Interview revealed a subcommittee was formed in September to address falls. Interview revealed the subcommittee had met once (week of October 5th) and hoped to have the next meeting next week, no date set. Interview revealed real time supervision, increase consistent staff, improve hand off communication, and pharmacy (medication) review of identified falls for the 900 (geriatric behavioral health) unit were discussed. Interview revealed the subcommittee identified the need for additional staff training for falls, and alarms for wheelchairs. Interview revealed the facility policy included stickers on the daily documentation forms, yellow socks, matts at the bedside, and dots on the whiteboards at the nursing station were to be used to identify falls risk patients.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, internal investigation review, observation, and staff and provider interviews, nursing staff failed to assess, supervise and monitor the care of geriatric behavioral health patients by failing to minimize fall and injury risk by not assessing fall risk per policy, implementing measures to prevent falls, and not completing a neurological assessment according to physician orders and/or facility policy for 7 of 10 sampled patients at high risk of falls (#7; #1; #3; #18; #19; #6; #17).

The findings include:

Review of the hospital policy titled "Edmonson Fall Reduction Assessment Policy," with revision date of 03/25/2020, revealed "Policy: Patient Safety is an ongoing responsibility of all staff. In order to reduce the risk of patient injuries as a result of a fall, the staff will assess and reassess the patient's level of risk for falls and in conjunction with the treatment team, institute appropriate interventions through the following procedures. ... Definition: A fall is defined as an event that results in the patient or any part of the patient's body coming to rest inadvertently on the floor or other surface lower than the patient's body. Purpose: To prevent falls and to limit injury from falling when it does occur. Procedure: The Edmonson Fall Risk Assessment will be completed by a Registered Nurse during the intake phase of admission. ... 1. Each patient will be reassessed each shift. 2. Reassessment must also be completed if there is a significant change in the patient's mental status or physical condition. ... 2. Patients with a score of 90 or greater will be classified as a Higher Risk for falls. 3. The Fall Prevention measures for patients at high risk must be implemented and appropriate equipment utilized by staff as indicated, for the patient's safety. ... C. Patients who score 90 or greater will be placed on the following precautions: a. Yellow ID Band b. Yellow non-skid socks b. High Risk--Patient will have: a. Yellow ID Band b. Yellow non-skid socks c. Yellow locator d. Fall Mat e. Magnetic Falling Star outside of patient's room f. Fall re-assessment every shift. ... IN THE EVENT OF A PATIENT FALL, WITH OR WITHOUT INJURY 1. The staff member discovering the fall will attend to the patient's immediate needs: a. A nurse will assess the patient immediately b. The attending physician will be promptly notified to determine the need for further evaluation ... e. Neurological checks and vital signs as ordered or appropriate for injury .. .i. Patient's fall risk will be reassess (sic) ... immediately after the fall ..."

1. Review of a closed medical record for Patient #7 revealed an [AGE] year old male with a history of dementia, TBI (traumatic brain injury) and CVA (cerebrovascular accident or stroke) was admitted on [DATE] at 1545 for evaluation of suicidal ideation. Review of the record revealed there was not an Edmonson Psychiatric Fall Risk Assessment documented from 09/24/2020 through 10/13/2020 (20 days); therefore, no documentation of a falls risk score was documented. Review revealed Patient #7 fell on [DATE] at 1830 and had an assisted fall on 09/28/2020 at 0345. Patient #7 was discharged to an ALF (assisted living facility) on 10/13/2020.

Review of an incident report for Patient #7 completed by RN #5 on 09/26/2020 at 1947 revealed the second fall was observed; however, no interventions were in place at the time of the fall.

Review of a signed statement from RN #9 dated 09/28/2020 revealed "MHT (Mental Health Technician) #14 who was sitting with Pt (sic), as LOSWA (line of sight while awake) reported that Pt. (sic) got up from his bed and was trying to ambulate but unable to, (sic) as he was going to fall, (sic) the MHT in the room with him lowered him to the floor to sit on his bottom. Writer was called in, (sic) pt. was assessed, (sic) No injuries noted, (sic) pt (sic) started crawling after he was assisted to the floor. NP on call notified, AOC notified (sic), family called no answer and voicemail left."

Interview on 10/14/2020 at 1111 with LPN #3 revealed the 900 Geriatric Behavioral Health Unit "does not utilize yellow stars on the patient doors to indicate a high risk for falls nor do they keep yellow armbands on the unit."

Interview on 10/14/2020 at 1443 with 900 Unit RN #5 revealed the yellow armbands are placed on falls risk patients during the admission process after the RN completed his/her assessment. Interview revealed she personally has never placed a yellow armband on a patient. Interview further revealed yellow nonskid socks are available throughout the facility and indicated a patient is a falls risk.

Interview on 10/14/2020 at 1618 with RN #9 revealed she "thinks day shift nurses complete falls risk shift assessments because patients are up during that shift". Interview further revealed RN #9 did not apply yellow armbands to patients and "thinks" the armbands are applied during the admission process.

Interview on 10/13/2020 at 1518 with RN #11 revealed a falls risk assessment should be completed daily. Interview further revealed the unit did not utilize stars outside of patient rooms. Interview revealed no falls risk assessment was documented on Patient #7 after his admission and prior to falling on 09/26/2020.

Interview with Director of Quality, Compliance and Risk Management on 10/15/2020 at 1408 revealed falls have been trending upward since May 2020. Interview revealed a Performance Improvement committee meeting was scheduled for Friday, 10/09/2020; however, was postponed. Interview revealed the goal is to have a meeting scheduled the week of 10/19/2020. Interview revealed the goal is to provide one to one coaching with LPN's (Licensed Practical Nurses) and CNA's regarding level of observations. Interview revealed the goal is to maintain consistency with staff so they can develop a rapport with patients. Interview revealed when hiring new staff facility will review qualifications to verify applicants are qualified to work with patients who are medically compromised. Interview revealed there was no falls risk assessment found in Patient #7's medical record.

2. Review of a closed medical record for Patient #1 revealed a [AGE] year old female with a history of vascular dementia (condition that causes memory loss in older adults), frequent falls, hearing loss, gait (manner of walking) disturbances and seizures was admitted on [DATE] at 1846 with a diagnosis of psychosis (severe mental disorder in which thought and emotions are impaired), rule out neurocognitive disorder (general term that describes decreased mental function due to a medical disease other than a psychiatric illness) and anxiety. Review of the history and physical examination documented on 09/24/2020 at 1810 revealed Patient #1 utilized a walker and wheelchair for mobility. Review of an Edmonson Psychiatric Fall Risk Assessment revealed a score of 101 (high falls risk) was documented on all shifts from 09/23/2020 through 09/25/2020 day shift. Review of the falls risk assessment for 09/25/2020 night shift showed no documentation for falls risk assessment. Review of patient observation rounds flowsheet revealed CNA (Certified Nursing Assistant) #10 documented Patient #1 was sleeping every 15 minutes on 09/25/2020 from 2100 until 09/26/2020 at 0030. Review further revealed a nursing note on 09/26/2020 (not timed) by RN (Registered Nurse) #9 stating Patient #1 was found on the floor sitting by her roommate's bedside with blood on the floor mat. RN #9's assessment indicated patient #1 had a laceration on the right side of her head above the ear and complained of right hip pain. Record review did not include a neurological assessment post fall. Record review revealed Patient #1 was transported to a local hospital on [DATE] and was found to have a broken hip.

Review of an internal investigative report documented on 10/07/2020 revealed "Conclusion: At the time of the incident Patient #1 was on line of sight while awake observation level. Patient #1 was found on the floor around 12:30 am, after staff heard a scream coming from her room. Several staff members entered Patient #1's room, including the nurse. Video review revealed that Patient #1 was in her room with the door closed, the staff that was assigned to do her Q15s (every 15 minute rounds), CNA #10 documented and reported during his interview that he monitored Patient #1. However, video review revealed that from 12:01 - 12:30 am, CNA #10 did not physically monitor Patient #1, per policy 1000.17- Levels of Observation." Review further revealed the facility substantiated the investigation as it was determined CNA #10's failure to provide proper documentation resulted in Patient #1 sustaining a fractured hip and head injury. CNA #10 was terminated as a result of the investigation.

Interview on 10/14/2020 at 1618 with RN #9 revealed she recalled Patient #1's fall. Interview revealed Patient #1 was in a wheelchair with yellow non-skid socks on at the beginning of the evening shift on 09/25/2020. Interview revealed RN #9 stated that she could not say she saw CNA #10 completing the Q15 minute checks on patients because she was "probably doing something else like 24-hour chart checks." Interview revealed RN #9 "thinks day shift nurses complete falls risk shift assessment because patients are up during that shift." Interview further revealed RN #9 did not apply yellow armbands to patients and "thinks" the armbands are applied during the admission process. Interview revealed if a patient fell on RN #9's shift, she would first attend to any injuries she could, complete a general and neurological assessment, obtain vital signs, call the on-call doctor, AOC (administrator on call) and family.

Interview on 10/14/2020 at 1111 with LPN (Licensed Practical Nurse) #3 revealed the 900 Geriatric Behavioral Health Unit "does not utilize yellow stars on the patient doors to indicate a high risk for falls nor do they keep yellow armbands on the unit."

Interview on 10/14/2020 at 1443 with RN #5 revealed she did not recall Patient #1. Interview revealed the yellow armbands are placed on falls risk patients during the admission process after the RN completed his/her assessment. Interview revealed she personally has never placed a yellow armband on a patient. Interview further revealed yellow nonskid socks are available throughout the facility and indicated a patient is a falls risk. Interview revealed no fall risk assessment was recorded on the night shift of 09/25/2020. Interview revealed if a patient fell on her shift and hit their head, the nurse would complete a neurological assessment. Interview revealed Patient #1 had a head injury from the fall and should have had a neurological assessment completed. Interview revealed no neurological assessment was documented for Patient #1 after the fall.





3. Review of a closed medical record for Patient #3 revealed the patient was transferred to and admitted on [DATE] at 1007 as Involuntary status with Unspecified Mood Disorder with homicidal ideations towards a family member. Review of nursing notes written by RN #17 dated 07/12/2020 at 0738 revealed "Pt. (Patient) was walking to his room, with walker when suddenly fell to the floor with (sic) his back. Pt hit his head. Pt was assisted to a chair. His vitals were BP (blood pressure) 167/77. O2 (oxygen) 96% (amount of oxygen in the blood), P (pulse) 96, Temp. (temperature) 97.3. No apparent injury but a small skin tear to the left thump (sic). Pt denies pain at time of fall. Said he was doing OK. Dr. notified and wife told of incident at 2000. Pt was able to talk with wife for along time. Continue to monitor for safety." Review of an Edmonson Psychiatric fall risk assessment on admission of 07/07/2020 revealed a score of 66, indicating low risk for falls. Review of an Edmonson psychiatric fall Risk assessment failed to reveal documentation of the fall risk assessment after the fall on 07/12/2020. Review of the falls risk assessment revealed the documentation revealed a falls risk assessment on 07/16/2020 (4 days after the fall).
Review of orders written by NP #1 dated 07/12/2020 at 1215 revealed "CSpine + KUB (abdominal xrays covering the kidneys, ureters and bladder) 2 views xray s/p (status post) fall. 2. Neuro (symbols showing check) 24 hr 3. Motrin 600 mg po BID x 7 days (Anti inflammatory by mouth twice daily for 7 days). Ice to head/neck." Review of the results of the x-ray of the abdomen dated 07/12/2020 at 6:16 PM revealed "...Nonobstructive bowel gas pattern." Review of the results of the Cervical Spine 2 or 3 views dated 07/12/2020 at 6:18 PM revealed "...Limited radiographic evaluation of the cervical spine without gross evidence of fracture...." Review of "Neurological Flow Sheet" dated 07/13/2020 at 0600 through 07/14/2020 at 0600 revealed no documentation of a neurological assessment at 1000, 1800, 2200, and 0200. Review revealed the handwritten word of "sleeping" during the undocumented assessments. Review revealed neurological checks were ordered for 24 hours with no frequency.
Review of a nurses note for Patient #3 written by the CNO dated 07/16/2020 at 0954 (4 days after the first fall) revealed "...@ 0930 resident found by staff sitting on bathroom floor. Resident states that he slipped. Resident states that he hit his head. (Physician group) notified, treatment plan in effect. Will continue to monitor for any changes."
Review of orders written by NP #1 dated 07/16/2020 at 1445 revealed "1. Abdomen 2 views. 2. C-Spine xray 3. Lt (left) thumb xray. s/p (status post) fall. 4. Neuro (symbol for check) hourly x 12 hours." Review revealed no documentation the neurological checks were done.

Interview on 10/14/2020 at 1605 with NP #1 revealed neurological checks as ordered should be done for safety. Interview revealed neurological checks are often ordered every one to two hours for 24-48 hours. Interview revealed patients should be awakened for a neurological evaluation. Interview revealed no documentation that neurological checks were done after the fall on 07/16/2020. Interview revealed the physician order was not followed.

Interview with RN #17 was not obtained due to RN #17 was no longer employed at the facility.

Interview on 10/13/2020 at 1515 with the CNO revealed no documentation of neurological checks. Interview revealed neurological checks should have been completed. Interview revealed the physician order was not followed.

4. Review of a physician's History and Physical dated 09/19/2020 at 1425 revealed Patient #18, a [AGE] year old male, was admitted on [DATE] for dementia. Review of the falls assessment revealed a score of above 90 (high risk) for 09/30/2020 through 10/12/2020 (high risk falls). Review revealed no documentation for falls scores on 10/02/2020, 10/03/2020 and 10/09/2020 (3 days). Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift.

Observation on 10/16/2020 at 1000 through 1040 of the geriatric behavioral health unit revealed Patient #18 was sitting at a table with no yellow arm band or yellow socks. Observation revealed no star on Patient #18's room.

Interview on 10/16/2020 at 1040 with CNA #16, who had been employed for one month, revealed all patients with a falls risk score of 85 or higher is a high risk for falls. Interview revealed CNA #16 has not seen any stars on patient doors in the past month. Interview revealed the falls stickers (silver) on the observation sheets indicate the patient is on falls precautions.

Interview on 10/16/2020 at 1050 with LPN #15 revealed all patients are discussed during end of shift report. Interview revealed the policy should be followed to reassess high risk patients every shift. Interviewed revealed there was no documentation of fall risk assessments for Patient #18 for 10/02/220, 10/03/2020 or 10/09/2020. Interview revealed fall risk assessments were not assessed and documented every shift according to policy. Interview revealed Patient #18 did not have a yellow arm band, or yellow non-skid sox on, or a falling star on the patient's room door. Interview revealed the facility falls policy was not followed.

5. Review of a History and Physical dated 08/29/2020 at 1700 revealed Patient #19, a [AGE] year old male, was admitted on [DATE] for dementia. Review of the falls assessment revealed a score of above 90 on 10/10/2020 through 10/12/2020 and 10/14/2020 and 10/15/2020. Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift.

Observation on 10/16/2020 at 1000 through 1040 of the geriatric behavioral health unit revealed Patient #19 was sitting at table with no yellow socks or no yellow armband. Observation revealed no star on the patient's room door.

Interview on 10/16/2020 at 1050 with LPN #15 revealed all patients are discussed during end of shift report. Interview revealed the policy should be followed to reassess high risk patients every shift. Interview revealed Patient #19 did not have a yellow arm band, or yellow non-skid sox on, or a falling star on the patient's room door. Interview revealed the facility falls policy was not followed.

Interview on 10/16/2020 at 1040 with CNA #16, who has been employed for one month, revealed all patients with a falls risk score of 85 or higher is a high risk for falls. Interview revealed CNA #16 has not seen any stars on patient doors in the past month.

6. Review of a History and Physical dated 10/05/2020 at 1510 revealed Patient #6, a [AGE] year old female, admitted on [DATE] for Major Depressive disorder. Review of the falls risk scores beginning on 10/05/2020 through 10/16/2020 revealed scores above 90. Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift from 10/05/2020 through 10/12/2020 (12 days).

Observation on 10/16/2020 at 1000 through 1045 of the geriatric behavioral health unit revealed Patient #6 was walking around the unit unattended. Observation revealed Patient #6 was not wearing a yellow arm band. Observation revealed no star on Patient #6's room door.

Interview on 10/16/2020 at 1050 with LPN #15 revealed all patients are discussed during the end of shift report. Interview revealed the policy should be followed to reassess high risk patients every shift. Interview revealed Patient #6 did not have a daily falls risk assessment, yellow arm band or falls star on the door.

7. Review of a History and Physical dated 10/14/2020 at 1915 revealed Patient #17, a [AGE] year old male, was admitted on [DATE] for schizophrenia. Review of a falls risk score of above 90 dated 10/14/2020 through 10/15/2020. Review of the medical record revealed documentation of falls risk scores was not done according to policy on each shift.

Observation on 10/16/2020 at 1000 through 1045 of the geriatric behavioral health unit revealed Patient #17 sitting in a chair with no fall star on his room door.

Interview on 10/16/2020 at 1040 with CNA #16, who has been employed for one month, revealed all patients with 85 or higher were a high risk for falls. Interview revealed CNA #16 has not seen any stars on patient doors in the past month.

In summary, nursing staff failed to ensure supervision and safety of the geriatric behavioral health patients by failing to follow the facility policy to assess patients' risk of falls, implement measures to prevent falls and perform neurological assessments after patient falls with head injuries.

NC 315; NC 634; NC 070; NC 146; NC 417; NC 648; NC 451; NC 430