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.

FREEDOM BEHAVIORAL HOSPITAL OF TOPEKA, LLC 1334 SW BUCHANAN STREET TOPEKA, KS 66604 March 25, 2020
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, document review, and policy review the hospital failed to ensure all nursing staff received appropriate orientation and competency assessments necessary to provide safe, effective care for 4 of 4 nursing staff reviewed (Staff I, agency registered nurse (RN), Staff G, agency RN, Staff F, hospital RN, and Staff H, RN, Director of Nursing [DON]) in a psychiatric hospital. Failure to ensure nursing staff received necessary training and failure to assess nursing staff competency following training placed all patients at risk for inadequate assessments, lack of nursing interventions, and the patients' inability to achieve goals and placed all patients at risk of poor nursing care and resulted in the delay of treatment and care and ongoing pain of one patient who fell with a serious injury (Patient 1) and one patient who fell with a minor injury (Patient 3).


Findings Include:


Review of the training and acknowledgement to be completed during orientation by both new hospital staff and contract staff included: Reduction of Falls, Complete and Compliant Medical Record Documentation, Treatment Plan/Updates: Master Plan, Fall Reduction presented by Staff W, Corporate RN, Medication Management policies and processes/Nursing Department, and Compliance with Policies, Nursing Order Guidelines, Purpose of 2567, presented by Staff H, Director of Nursing (DON), Prevention of Future Incidents, presented by Staff M, Quality Director.


Each training document stated the following, "I confirm that I attended a training session listed above. I observed, listened, read, and understood the content of the training, and I understand that as an employee, it is my responsibility to abide by [Hospital] process, policy, and the organizations procedures in accordance with the training," followed by an employee signature line with date and trainer signature line with date.


Review of the undated document titled, "General Orientation Schedule/Acknowledgement," for hospital employees showed orientation requires three days to complete and includes presentations by the DON, Life Safety Director, Human Resources Director, Health Information Manager, Administrator, Activities Director, Clinical Services Director, and Administrator.


Review of the undated document titled, "Vendor Packet," showed, "Purpose: To provide a short, concise orientation to the major factors that drive our facility and the care of our patients. This allows a means to ensure the safety of all involved. We provide a safe environment for our patients, visitors, and employees. Safety is an integral requirement in the delivery of high quality health care in a financially responsible manner. Providing services to behavioral health clients gives us greater challenges to ensure everyone's safety."


Review of the nursing schedule from 02/19/20 through 03/21/20 showed the hospital has two full time Registered Nurses (RN), one Director of Nursing (DON), and contracts with two agencies who provide supplemental RNs. The hospital staffs two shifts, 7:00 AM to 7:00 PM and 7:00 PM to 7:00 AM daily with two RNs each shift. Each RN works approximately three 12-hour shifts per week requiring additional contract staff to cover the remaining shifts weekly.


Personnel records reviewed on 03/18/20 showed:


Staff G, agency RN, with an undocumented start date at the hospital, showed no documentation of orientation or policy/procedure training.


During an interview on 03/18/20 at 4:47, Staff H, RN, DON verified by looking at Staff G's personnel record that she had no orientation documentation signed to indicate the training was completed.


During an interview on 03/25/20 at 11:45 AM, Staff V, Human Resource Director verified that the personnel record for Staff G, Agency RN, failed to have any orientation documents signed.


Staff E, agency RN, started working at the hospital on [DATE] and she read the falls sheet and signed it on 03/16/20 (one week after she started working).


During an interview on 03/18/20 at 6:30 PM, Staff E, Agency RN, stated she has worked at this facility for two weeks. She stated orientation consisted of completing some forms she received when she arrived on her first day at the facility and then she went directly to the floor to start her shift. Staff H, Director of Nursing (DON) provided orientation "hit and miss" and Staff F, RN provided some of the orientation. She stated, "orientation is not sufficient." She further stated she had no experience working in a psychiatric hospital.


Staff F, hospital RN, employment date 12/27/18, lacked evidence of training for Reduction of Falls.


Staff H, RN, DON, employment date 12/31/19, lacked evidence of training for Reduction of Falls.


All personnel files reviewed lacked evidence of nursing competency assessments performed by administrative staff, the DON or the Corporate RN.


Additional information provided on 03/24/20, Staff L, Chief Executive Officer (CEO) brought in different personnel files for the above four staff whose personnel files were reviewed on 03/18/20. The sheets regarding falls were handed to me separately and he stated they were on a shelf in the HR director's office. When he was asked why they were not in the personnel record last week, he did not respond.


Review of the personnel records on 03/24/20 showed:


Staff E, agency RN, had signed that she read the falls policy on 03/16/20 and on 03/24/20.


During an interview on 03/24/20 at 2:54 PM, Staff E, Agency RN, stated that the way the facility trains the agency nurses is to have them watch videos and then sign off they watched them. She clarified the reason why she has two different dates for the same falls policy training is that she did it on 03/16/20 and they could not find it, so she had to re-take it on 03/24/20. She also clarified they take the trainings on their days off.


Staff G, agency RN, had signed that she read the falls and several other policies on 03/15/20.


Staff F, hospital RN, had signed that she read the falls and several other policies on 03/20/20.


During an interview on 03/24/20 at 2:30 PM, Staff F, RN stated that she did not work on 03/20/20. She explained she was off from 03/19/20 to 03/22/20. She was asked to explain how all her training was dated as completed on 03/20/20 when she was off, and she stated the facility will pay them to do training at home. So, on 03/20/20 she spent about eight hours going through all her required training. Staff F stated Staff M, Quality Manager provided fall training approximately three weeks previously. She stated the post fall assessment includes a neurological check if there is a fall and the care plan must be changed to show fall risks and interventions. She commented it is mentally fatiguing to keep up with all the changes the facility puts out. She further commented that every month there are changes and sometimes they are for the same thing. She also commented on the new change posted this morning concerning falls, "It is the same as before except some things are emphasized stronger."


Staff H, RN, DON, had signed that she read the falls and several other policies on 03/20/20.



During an interview on 03/18/20 at 7:00 PM, Staff N, Agency RN stated he has worked at the facility for about two months and there was no "real orientation" but rather he sat with another nurse who explained some procedures and policies. He further stated that he is scheduled for a class in a week regarding patient admissions. Additionally, he stated that there was no specific training regarding falls, he just completed paperwork and signed it.


During an interview on 03/18/20 at 4:48 PM, Staff H, DON, stated agency staff orientation consists of a vendor packet that new contracted staff receive either before they start at the hospital or on the first day they report for duty at the hospital. The packet and orientation are done within the first day or two, so they might be working on the floor without completing orientation. The vendor packet includes the same information hospital staff receive during orientation.



Patient 1


Review of Patient 1's medical record showed she was an [AGE] year-old female with a voluntary admission to this psychiatric hospital on [DATE] with diagnoses of [DIAGNOSES REDACTED] (under active thyroid), and congestive heart failure (CHF) (inability of the heart to pump blood properly).


Review of the admission nursing assessment completed on 03/11/20 by Staff P, Registered Nurse (RN) showed she was admitted from an assisted living facility after she became aggressive to staff and other patients. At admission documentation showed she was ambulatory requiring no assistance, had no alterations in mobility or comfort. Her fall risk score was 15 showing she was at moderate risk of falls due to age, medications, confusion, and poor balance requiring the initiation of fall precautions. She was placed on close observation for violence, falls, and elopement requiring documentation every 15 minutes of her location and activity.


Review of orders signed by Staff Q, Psychiatrist, on 03/12/20 for Patient 1 included vital signs twice daily (BID), observation every 15 minutes, reconciliation of home medications, and as needed (prn) Tylenol 325 mg(milligrams), two tablets by mouth every eight hours for temperature over 100 degrees or for pain, EKG, and lab including TSH (thyroid), vitamin B12 level, Vitamin D level, and lipid panel. Additional orders by Staff Q on 03/12/20 showed the discontinuation of Abilify (antipsychotic), Buspar (antidepressant), and Zoloft (antidepressant) and the addition of Risperdal (antipsychotic) 0.5 mg PO at night and Remeron (antidepressant)7.5 mg PO at night.


Review of the document titled, "Master Treatment Plan of Care: Fall Precautions", for Patient 1 included treatment team goals including, "Will remain free from falls ...Assist with toilet and ask for assistance and pushing call light." Nursing Interventions included the following, "Patient 1 will be assessed each shift for sedation, Will provide education if needed, and Assist with toileting every two hours."


Documentation on 03/15/20 at 7:30 AM, the nursing daily note by Staff F, RN showed Patient 1 was exit seeking, wandering the halls, upset with redirection, and confusion.

Review of the "At Risk for Falls (ARF) Score Sheet", revised on 02/26/17, showed, ... "Patient Scoring 8 -24 Moderate Risk (Initiate Fall Precautions). FALL PRECAUTIONS for Patients at Moderate/High Risk: ... Patient Is Not Left Unattended During Activities That Place Him/Her At Increased Risk of Falling."

During a telephone interview with Staff G, agency RN, on 03/19/20 at 9:06 AM she stated that on 03/15/20 around 6:15 PM, she was putting the fire alarm cap back on after Patient 1 set it off. Patient 1 was walking without assistance in the hallway and then after she set the fire alarm off, she was "running" down the hall. Nursing staff failed to accompany Patient 1 while she was acting out (setting off the fire alarm) and "running" down the hallway. Per policy, the patient should not have been left unattended during these activities that put her at increased risk of falling. She further stated that following the fall, Patient 1 refused to allow vital signs and she "acted like her leg hurt, but there was not anything physical that we could see". When we got her up we walked her about 4 feet to her bed. "We performed an assessment including her leg, however without removing her pants all the way but could see her hip."


Review of the "ARF Score Sheet" showed Staff I reassessed Patient1's fall risk on 03/15/20 at an undocumented time with a score of 15 and Staff H, DON reassessed Patient 1's fall risk again on 03/15/20 at an undocumented time with a score of 20. Nursing Staff failed to time the entries into the medical record.


Review of the "Multi-Disciplinary Note," dated 03/15/20 at 6:15 PM by Staff F RN, showed, Patient 1 "Put self on floor and c/o (complained of) right lower extremity (RLE) pain. Order for two view X-ray obtained." The medical record lacked documentation that Staff F, RN transcribed a physician's order for the X-rays of Patient 1 when she notified Staff K, Doctor of Osteopathy (DO) of the patient's fall on 03/15/20 at 6:30 PM. The medical record failed to contain any documentation of the information that Staff F, RN shared with Staff K, DO about Patient 1's condition after her fall.


During an interview on 03/18/20 at 4:00 PM, Staff F, RN said she was at the desk on 03/15/20 when Patient 1 fell , but she did not see her fall. She stated, "I heard Patient 1 say, "I'm falling" and by the time I stood up she was on the floor on her left side." Patient 1 immediately complained of right leg pain. She then stated the three-staff helped her up and got her into bed. Patient 1 did not bear weight on the right. Staff F, RN stated vital signs were stable and the patient was assessed. Patient 1 was unable to describe the pain. The assessment showed she had external rotation, no shortening, and was able to pull her knee up a little bit. She was combative and aggressive. Staff F stated that she notified Staff K, DO of the fall and he ordered an X-ray. Staff F, RN said that there was no discussion with Staff K, DO regarding sending Patient 1 to the hospital nor was anything ordered for pain. Patient 1 had a standing prn order for Tylenol. She stated she called the mobile X-ray company after she received the order from Staff K. She then stated, "It is my understanding that X-ray did not come out until the next day." Patient 1 did complain of pain, but only when she was moved. Staff F further stated during her post fall assessment she was able to localize the pain to the right leg and the "leg was definitely rotated out". She then stated she told Staff K, DO that the leg had slight rotation out, some shortening, and she was in pain.

Review of the hospital policy titled, "Patient Fall Risk", revised 12/16 showed, ... "The ...Psychiatrist will be contacted by the charge nurse to determine the course of treatment after the patient has fallen".

Review of the hospital policy titled, "Incident Report", revised 12/16, showed, ... "Incident reports are a confidential document for facility use only."


The medical record lacked any evidence that Staff F notified the physician of Patient 1's inability to bear weight on her right leg and that the patient had 10/10 sharp, constant pain. Her documentation of 10/10 pain on the "Post Fall Assessment" contradicts her interview statement that Patient 1 was unable to describe the pain. Per interview, the patient's right leg had slight rotation out and some shortening (displaced fractures of the femoral neck will classically cause external rotation and shortening of the leg when the patient is laying supine). The medical record lacked any evidence that Patient 1 had external rotation and shortening. The "Incident/Accident Report" contained one set of vital signs, however, this document is not part of the patient's medical record. The medical record lacked documentation that Staff F or any other nursing staff contacted the Psychiatrist after Patient 1's fall per policy. The medical record failed to contain any documentation Staff F or any other nursing staff notified the mobile X-ray company after nursing staff received the order for the portable X-ray on 03/15/20 at 6:30 PM.

During an interview on 03/23/20 at 10:46 AM, Staff H, DON stated that she was at the facility the day Patient 1 fell . She stated that she did not do an assessment but did see the presence of leg swelling. She instructed the nurse (Staff F) to contact the physician and have Patient 1 sent to the emergency department (ED). The nurse called Staff K, DO who ordered a portable X-ray instead. Staff H stated that if a nurse does not agree with a physician's order they are to call the DON or the administrator on call (AOC).


Review of the hospital policy titled, "Post Fall Process", revised on 3/17, showed, "In the event that a patient experiences a fall, the following process will be followed: medical care provided if injury is sustained and under the orders of the physician; the Post Fall Assessment Form will be completed after a patient has fallen; and notification to the DON."

Review of the document titled, "Post Fall Assessment", completed by Staff F, RN on 03/15/20 at 6:45 PM showed vital signs and neurological assessment should be completed every 15 minutes times two, every 30 minutes times two, every hour times two, and every four hours times two following a fall. Nursing staff (Staff F, Staff I, or any other nurse) did not complete any vital signs on this form and completed only two sets of untimed vital signs on the "Graphics/Vital Signs Flowsheet" on 03/15/20. Nursing Staff F documented only one neurological assessment on the form on 03/15/20. Staff F, Staff I, or any other nurse failed to document or assess Patient 1's neurological status any further on the "Post Fall Assessment" for the 7.5 hours following Patient 1's fall. Staff F, RN further documented on the "Post Fall Assessment" form that Patient 1 had decreased range of motion of her RLE, a pain level rated 10 out of 10 (0 no pain, 10 worse pain), described as sharp and constant. The medical record lacked any evidence that Staff F or any other nursing staff administered any pain medication to Patient 1 at the time of the fall for her c/o 10/10, sharp, constant pain or obtained a physician's order for any stronger pain medication than the Tylenol Patient 1 already had ordered at admission. The medical record lacked any evidence that Staff F notified the physician of the external rotation of Patient 1's RLE which is a sign of a femur fracture. Staff F and Staff I failed to fill out the "Post Fall Assessment" form completely per policy.

Nursing staff failed to fill out the "RN Post Fall Screen for Fall Precautions" completely and accurately. Nursing staff failed to mark "Yes" or "No" to the question about the use of assisted [sic] devices. Nursing staff failed to indicate that Patient 1 used a walker as documented on nursing assessment. Nursing staff failed to mark "Yes" or "No" to the question about over sedation. Nursing staff failed to mark "Yes" or "No" to the question about Blood pressure (BP) (orthostatic hypotension) although "Lying" is checked and a BP of 112/58 was documented on the line labeled, Irregular pulse rate. Nursing staff failed to mark "Yes" or "No" to the question about Irregular pulse rate and there is no other number documented on the form to indicate Patient 1's pulse. Nursing staff failed to circle either "Mild", "Moderate", or "High" on the question about fall "Level Identified". Nursing failed to mark "Yes" or "No" to the question about whether "Interventions changed on treatment plan".

Review of the document titled, "Fall Analysis Form," showed, Staff G, RN indicated the fall was not medication related, but was related to the patient's mental health. She further document X-rays were ordered, and the activities/processes occurring at the time of the fall could cause the fall. Staff H, DON did not sign the document even though she indicated that she was present at the facility the day Patient 1 fell and Staff F, Staff I or any other nursing staff failed to document notification of the Patient 1's fall to the DON.

Nursing Staff failed to fill out the "Fall Analysis Form" dated 03/15/20 completely and correctly. Nursing Staff documented Patient 1 was identified as a fall risk on admission but marked "NA" (not applicable) to the question, "Was the Fall Risk Protocol implemented and documented after admit/prior to fall?". Nursing staff marked "NA" to the question "Were any environmental factors involved in this event?" Even though, the next line asks the recorder to "Please identify the environmental factor" and the nursing staff documented, "Turning on fire alarm." Nursing staff marked both "Yes" and "No" to the question, "Was staffing adequate according to grid?". Nursing staff marked "Yes" to the question, "Activities/processes occurring at this time that could be factors in cause of this event?" However, nursing staff failed to identify what activity/process was a factor in Patient 1's fall.


Review of the hospital policy titled, "Incident Report", revised 12/16, showed, ... "All sections of the Incident report must be completed."

Nursing staff failed to fill out the "Incident/Accident Report" dated 03/15/20 completely. Nursing staff failed to complete the section of the report asking for "Previous Fall Score and New Fall Score".


Staff I, RN documented on a "Nursing Daily Note" on 03/15/20 at 10:00 PM that Patient 1 had a complaint of (c/o) pain 10/10 of her RLE when the nurse administered her night time medications and so she gave Patient 1 650 mg (milligrams) of Tylenol (APAP - analgesic that treats mild aches and pains) at 9:05 PM (about 2 hours and 50 minutes after the fall). Staff I, RN indicated the APAP was ineffective and she called the doctor and received an order for the narcotic pain medication, Norco. The record showed that nursing staff administered Norco at 10:35 PM and that Patient 1 fell asleep.

During a telephone interview with Staff I, Agency RN on 03/19/20 at 10:17 AM, she stated that the night Patient 1 fell during the prior shift, Staff F had obtained an order for an X-ray from Staff K, DO but it was not a STAT order. After report, she stated Patient 1 was in bed and not complaining of pain at that time. Staff I, RN stated later into the shift Patient 1 started complaining of pain and I gave her Tylenol which seemed to relieve the pain until 10:00 to 10:30 PM when the pain became worse. She stated she contacted Staff K, DO who gave an order for Norco which I gave Patient 1 every four hours during the night. At some point, she stated the mobile X-ray company called stating they would not be available to do the X-rays until midnight and Staff I, RN told them to wait until morning because the patient was sleeping. She stated she gave that information to Staff K, DO when she called for the pain medication order. He told her if the pain medication did not keep her comfortable to call him again and he would send her to the ED. Because the pain was relieved she did not call the doctor back. She stated staff repositioned her several times during the shift and she remained comfortable. During the night chart audit, she stated that she did not see the order for Patient 1's mobile X-ray.


Additionally, the medical record showed that Staff I, RN administered Norco on 3/16/20 at 2:30 AM for c/o 10/10 pain in the RLE and on 3/16/20 at 6:30 AM for c/o 10/10 pain in the RLE.


The medical record lacked evidence that Staff I obtained an order from Staff K, DO to hold the X-ray until the morning. After she conducted the night chart audit and found the order for Patient 1's X-rays missing, Staff I failed to obtain an order for the X-ray from Staff K, DO that had not been transcribed by Staff F, RN.


The medical record showed that Staff E, Agency RN administered Norco on 3/16/20 at 11:15 AM for c/o 10/10 pain in the RLE. The medical record lacked evidence that Staff E assessed or documented Patient 1's response to pain medication administered on 03/16/20 at 11:15 AM.

The medical record showed an order for an X-ray of Patient 1's right hip and right upper leg on 03/16/20 at 1:30 PM (around 19 hours after the fall) and Staff E failed to write the order as STAT. The mobile X-ray company performed Patient 1's X-rays on 03/16/20 at 1:43 PM (around 19.5 hours after the fall).

Documentation from the mobile X-ray company showed they arrived at the hospital on [DATE] at 1:43 PM and performed an X-ray of both hips and the right femur. Their clinical note showed a right femoral neck fracture and the results were called to nursing staff at the hospital on [DATE] at 3:30 PM.

The medical record failed to indicate whether the order received by the nursing staff on 03/16/20 at 1:30 PM for a straight cath (catheter) (used to take a sample of urine from a patient, meant for temporary use and is removed and disposed of or sterilized immediately afterwards), urinalysis with culture and sensitivity, and X-ray to right hip and right upper leg was a telephone or verbal order, the name of the Doctor who gave the order, and a read back verification of the order. The order did contain Staff K, DO's undated, untimed signature.

The medical record showed that Patient 1 did not transfer to the local acute care hospital's (hospital B's) emergency department (ED) on 03/16/20 until 4:30 PM (around 22 hours after the fall) for treatment of a right femoral neck fracture from the fall that occurred on 03/15/20 at 6:15 PM.

Medical record from the acute care hospital B showed that Patient 1 had surgical repair of the right hip on 03/17/20.

During an interview on 03/18/20 at 6:30 PM, Staff E, Agency RN, stated she has worked at this facility for two weeks. She stated she worked the nursing desk on 03/16/20 starting at 7:00 AM. She performed an assessment of Patient 1 and saw the right leg rotated out and 3 inches shorter than the left with minimal bruising. She was told in report that Patient 1 had fallen the evening before. She stated she called the mobile X-ray company to ask about an expected time of arrival to perform Patient 1's X-rays and was told it "would be pretty soon." She further stated that she called Staff K, DO and he did not answer. She stated that she didn't remember what time she made the first call. She called Staff K, DO for a second time on 03/16/20 at 10:34 AM and told him the X-ray had not been performed, gave him the results of her assessment, and he made the decision to wait to transfer Patient 1 to the ED until after the X-ray results were available. Staff E, RN stated that she was unable to find the original X-ray order, so she wrote the order and called the mobile X-ray company again at 12:20 PM. Mobile X-ray arrived shortly after the last phone call and the results of fractured femur were reported. Staff K, DO came into the facility at some time around the time the mobile X-ray company came. He signed the order but did not assess the patient. Staff E, RN stated she reported her assessment to Staff H, DON including her belief Patient 1 had a RLE displacement or fracture and Staff K, DO refused to send her to the hospital prior to the X-ray. "I do not know if Staff H, DON assessed Patient 1, but I do know she was aware I had called X-ray a couple of times."

The medical record lacked documentation that Staff E notified Staff K, DO of the X-ray results on 03/16/20. The medical record lacked evidence of documentation that Staff E transcribed Patient 1's transfer order to the acute care hospital on [DATE]. The medical record lacked evidence that Staff E documented vital signs on the "Graphics/Vital Signs Flowsheet" on 03/16/20. The medical record lacked evidence of nursing assessment or documentation of fifteen-minute checks on the "Close Observation Sheet" on 03/16/20.

The medical record lacked evidence of the phone calls Staff E made to the mobile X-ray company or the requests or inquiries made on 03/16/20. The medical record lacked evidence that Staff E, RN documented the conversations she had with the DON expressing concerns about Patient 1's care (information obtained by interview): She said that she assessed Patient 1 and her leg was rolled out and was 3" shorter. She had only minimal bruising. She stated that she called the Physician and he did not answer (didn't recall the time of the first call) and so she called back at 10:34 AM and told him X-ray had not come out and gave him the results of her assessment, asking if Patient 1 could transfer to the hospital. She stated that he said to wait to transfer the patient until after the X-ray. Nursing staff called the mobile X-ray company around 12:20 PM and changed the priority of the X-ray to STAT. The nursing staff said that she had a couple of conversations with the Director of Nursing (DON) regarding concerns about Patient 1's injury and waiting for the portable X-ray instead of transferring the patient to the local acute care hospital. The medical record lacked documentation of these conversations and there was no documentation in the medical record indicating that the DON reviewed the situation or took any actions on behalf of Patient 1.

During a telephone interview on 03/19/20 at 8:13 AM, Staff J, Supervisor of the contracted mobile X-ray company, stated Staff X, Receptionist received orders from a staff RN at the hospital for a right hip and right femur X-ray post fall per Staff K, DO on 03/15/20 at 6:43 PM. The order was not flagged as STAT (immediately). On 03/15/20 at 10:23 PM, X-ray technician Staff Y documented the X-ray would be rescheduled for 03/16/20 per a hospital nurse. Further documentation by dispatcher Staff Z showed that a hospital nurse called on 03/16/20 and asked if the X-ray was going to be done this morning. At that time, the order was changed to STAT. Staff Z sent a message to an X-ray technician at 12:33 PM requesting an estimated time of arrival. The X-ray was taken at 2:02 PM. The results showing a right femoral neck fracture were faxed on 03/16/20 at 2:25 PM to the hospital and we also notified the hospital nurse by telephone.


During telephone interview on 03/19/2020 at 7:38 AM, Staff K, DO, stated he did not remember what day or time he was called about Patient 1 following her fall, but remembered getting a call from a nurse and giving an order for a portable X-ray. He stated the decision to not send her to the ED for an evaluation was based on the nursing assessment given to him over the phone. The RN giving the report did not suspect a fracture. He stated he received a second call at an unknown date or time by a nurse with a report that the X-ray had been completed and he thought she was transported to the ED prior to being seen by him or one of his mid-levels. Staff K, DO had no recall of being at the hospital on [DATE] or of giving orders for additional pain medication during the night. Staff K, DO stated he depends on the nursing assessment to help make his medical decisions.

During a second interview on 03/23/20 at 1:22 PM, Staff K stated he told the nurse to send Patient 1 to the ED and the nurse offered a mobile X-ray first and he agreed. He clarified the X-ray was not ordered STAT, but just to be done the same day, but sometime on 03/16/20 staff called and told him the X-ray was not done. Staff K reviewed the orders for Patient 1 and verified there was not a physician's order written by nursing as a telephone order for the X-ray he requested on 03/15/20. He was notified by a nurse "at some time" that her (Patient 1's) leg was rotated and shortened but did not recall when he received the information.

During an interview on 03/18/20 at 4:48 PM, Staff H, DON stated that she spoke with Staff K, DO regarding Patient 1's X-ray orders and the delay in obtaining the X-rays. He told her the initial X-ray was ordered STAT (immediately). He further told her X-ray called at midnight and asked to perform the X-ray in the AM and staff called him to verify he would authorize the delay.

During another interview on 03/23/20 at 10:46 AM, Staff H, DON stated that she was unaware Staff K, DO was in the building the next day, Monday 03/16/20 and stated since he was in the building her expectation would be that would have assessed Patient 1.

During an interview on 03/23/20 at 11:05 AM, Staff L, CEO stated that an administrator is always on call 24/7 and all clinical questions are deferred to Staff H, DON. If she is unavailable then the physician, or the charge nurse would make the decision. Staff L stated if the nurse disagrees with the physician's order the nurse can speak with the hospital corporate nurse. He did state that he does know the "nurse's scope allows them to push back anytime they want." The administrator on-call list with phone numbers are posted in the nurse's station. Staff L further stated that he was unaware Staff K,
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, document review, personnel record review and policy review the Director of Nursing (DON) and the hospital failed to ensure nurses were oriented to policies and procedures prior to providing care for four of four staff personnel records reviewed (Staff E, F, G and H) and per interview with Staff N, Agency RN, and failed to ensure policy and procedures were followed by nursing staff related to falls, nursing documentation and physician orders for two of three patients with falls (Patients 1 and 3). The DON and hospital's failure to ensure nurses are oriented to policies prior to working, and policy and procedures are followed by all nursing staff has the potential to place all patients at risk for receiving to care that fails to meet state and federal regulations and standards for nursing care.

Findings Include:

Review of the hospital's undated document titled, "Vendor Packet," showed agency nurses are to sign a vendor packet orientation sheet and the staff are to sign and date they attended the training session, they observed, listened, read and understood the content and it is there responsibility to abide by the process, policy, and the organizations procedures in accordance with the training. They may ask questions and seek clarification in writing or contact the human resource department. The trainers are different for each policy. Trainers include Staff W, Corporate RN and Staff H, RN, Director of Nursing (DON).

Review of the hospital's undated document titled, "General Orientation Schedule/Acknowledgment," showed, the hospital's nurses receive a three-day orientation which includes training on the nursing policies and procedures.
Review of the hospital's training document titled, "To Reduce Falls," predated 03/20/20, showed 23 focus topics to cover concerning falls and 11 topics to cover concerning the post fall process.


Review of personnel files on 03/18/20 for Staff E and G, agency staff personnel showed the following:

Staff E, agency RN, started working at the hospital on [DATE] and she read the falls sheet and signed it on 03/16/20 (one week after she started working).

During an interview on 03/18/20 at 6:30 PM, Staff E, Agency RN, stated she has worked at this facility for two weeks. She stated orientation consisted of completing some forms she received when she arrived on her first day at the facility and then she went directly to the floor to start her shift. Staff H, Director of Nursing (DON) provided orientation "hit and miss" and Staff F, RN provided some of the orientation. She stated, "orientation is not sufficient." She further stated she had no experience working in a psychiatric hospital.

Staff G, agency RN, with an undocumented start date at the hospital, showed no documentation of orientation or policy/procedure training.

During an interview on 03/18/20 at 4:47, Staff H, RN, DON verified by looking at Staff G's personnel record that she had no orientation documentation signed to indicate the training was completed.

During an interview on 03/25/20 at 11:45 AM, Staff V, Human Resource Director verified that the personnel record for Staff G, Agency RN, failed to have any orientation documents signed.


During an interview on 03/18/20 at 7:00 PM, Staff N, Agency RN (personnel file not reviewed) stated he has worked at the facility for about two months and there was no "real orientation" but rather he sat with another nurse who explained procedures and policies. He stated that he is scheduled for a class in a week regarding patient admissions. He further stated there was no specific training regarding falls, he just completed some paperwork.
During an interview on 03/18/20 at 4:48 PM, Staff H, DON stated agency staff orientation consists of a vendor packet that new contracted staff receive either before they start at the hospital or on the first day they report for duty at the hospital. The packet and orientation are done within the first day or two and they might be on the floor without orientation. The vendor packet includes the same information hospital staff receive during orientation.

Review of personnel files on 03/18/20 for Staff F and H, hospital personnel, showed the following:

Staff F, hospital RN, employment date 12/27/18, lacked evidence of training for Reduction of Falls.

Staff H, RN, DON, employment date 12/31/19, lacked evidence of training for Reduction of Falls.

All personnel files reviewed lacked evidence of nursing competency assessments performed by administrative staff, the DON or the Corporate RN.


Additional information provided on 03/24/20, Staff L, Chief Executive Officer (CEO) brought in different personnel files for the above four staff whose personnel files were reviewed on 03/18/20 and he explained the files were in the HR director's office. The sheets regarding falls were handed to me separately and he stated they were on a shelf in the HR director's office.

Review of the additional information provided for the personnel records on 03/24/20 showed:

Staff E, agency RN, had signed that she read the falls policy on 03/16/20 and on 03/24/20.

During an interview on 03/24/20 at 2:54 PM, Staff E, Agency RN, stated that the way the facility trains the agency nurses is to have them watch videos and then sign off they watched them. She clarified the reason why she has two different dates for the same falls policy training is that she did it on 03/16/20 and they could not find it, so she had to re-take it on 03/24/20. She also clarified they take the trainings on their days off.

Staff G, agency RN, had signed that she read the falls and several other policies on 03/15/20.

Staff F, hospital RN, had signed that she read the falls and several other policies on 03/20/20.

During an interview on 03/24/20 at 2:30 PM, Staff F, RN stated that she did not work on 03/20/20. She explained she was off from 03/19/20 to 03/22/20. She was asked to explain how all her training was dated as completed on 03/20/20 when she was off, and she stated the facility will pay them to do training at home. So, on 03/20/20 she spent about eight hours going through all her required training. Staff F stated Staff M, Quality Manager provided fall training approximately three weeks previously. She stated the post fall assessment includes a neurological check if there is a fall and the care plan must be changed to show fall risks and interventions. She commented it is mentally fatiguing to keep up with all the changes the facility puts out. She further commented that every month there are changes and sometimes they are for the same thing. She also commented on the new change posted this morning concerning falls, "It is the same as before except some things are emphasized stronger."


Staff H, RN, DON, had signed that she read the falls and several other policies on 03/20/20.


Review of the hospital's policy titled, "Assessment - Fall," dated 03/17, showed ...to prevent a patient from falling during hospitalization ...to provide appropriate interventions for patients identified as a fall risk ...to provide a safe environment for all patients during hospitalization ...fall prevention adjusted as indicted by the team ...medical care provided if injury is sustained and under the orders of a physician ...notification to the director of nursing ...the patient will be identified as a fall risk after falling, if not done so upon admission.

Review of the hospital's undated policy titled, "Nursing Documentation," showed ...the nurse can document their assessment and findings in two different ways. The daily nursing progress note and/or the multidisciplinary progress note ...documentation of nursing care is to be pertinent, concise and reflect the patients status ...nursing documentation addresses the patient's needs, problems, capabilities and limitations ...nursing interventions and patient responses are to be noted in the daily nursing progress note each shift, incorporating the elements of the nursing process and treatment plan ...if additional information, space an unusual event, or abnormal findings are pertinent to the nurses assessment that day, then an additional entry can be made ...all documentation will be performed in a timely manner.

Review of undated document titled, "Verbal Orders Guidelines," showed, "All verbal orders are immediately written and signed by the individual receiving the order indicating: the date and time the order was issued; the signature and credentials of the recipient (at least first initial and full last name; the name and credentials of the individual giving the order; and the name and credentials of the original author of the order (if different than the individual communicating the order".

Review of the hospital's policy titled, "Prescribing/Ordering-General Practices," reference #7014 showed two copies of the same policy one dated 11/16 and the other undated with some information that was different on each policy. The combination of the two policies with the same title and reference number showed ...all orders for ...treatment must be documented in the patient's medical record ...verbal orders are to be written immediately.


Patient 1

Review of Patient 1's medical record showed she was an [AGE] year-old female with a voluntary admission to this psychiatric hospital on [DATE] with diagnoses of [DIAGNOSES REDACTED] (under active thyroid), and congestive heart failure (CHF) (inability of the heart to pump blood properly).

Review of the admission nursing assessment completed on 03/11/20 by Staff P, Registered Nurse (RN) showed she was admitted from an assisted living facility after she became aggressive to staff and other patients. At admission documentation showed she was ambulatory requiring no assistance, had no alterations in mobility or comfort. Her fall risk score was 15 showing she was at moderate risk of falls due to age, medications, confusion, and poor balance requiring the initiation of fall precautions. She was placed on close observation for violence, falls, and elopement requiring documentation every 15 minutes of her location and activity.

Review of orders signed by Staff Q, Psychiatrist, on 03/12/20 for Patient 1 included vital signs twice daily (BID), observation every 15 minutes, reconciliation of home medications, and as needed (prn) Tylenol 325 mg(milligrams), two tablets by mouth every eight hours for temperature over 100 degrees or for pain, EKG, and lab including TSH (thyroid), vitamin B12 level, Vitamin D level, and lipid panel. Additional orders by Staff Q on 03/12/20 showed the discontinuation of Abilify (antipsychotic), Buspar (antidepressant), and Zoloft (antidepressant) and the addition of Risperdal (antipsychotic) 0.5 mg PO at night and Remeron (antidepressant)7.5 mg PO at night.

Review of the document titled, "Master Treatment Plan of Care: Fall Precautions", for Patient 1 included treatment team goals including, "Will remain free from falls ...Assist with toilet and ask for assistance and pushing call light." Nursing Interventions included the following, "Patient 1 will be assessed each shift for sedation, Will provide education if needed, and Assist with toileting every two hours."

Documentation on 03/15/20 at 7:30 AM, the nursing daily note by Staff F, RN showed Patient 1 was exit seeking, wandering the halls, upset with redirection, and confusion.

Review of the "At Risk for Falls (ARF) Score Sheet", revised on 02/26/17, showed, ... "Patient Scoring 8 -24 Moderate Risk (Initiate Fall Precautions). FALL PRECAUTIONS for Patients at Moderate/High Risk: ... Patient Is Not Left Unattended During Activities That Place Him/Her At Increased Risk of Falling."

During a telephone interview with Staff G, agency RN, on 03/19/20 at 9:06 AM she stated that on 03/15/20 around 6:15 PM, she was putting the fire alarm cap back on after Patient 1 set it off. Patient 1 was walking without assistance in the hallway and then after she set the fire alarm off, she was "running" down the hall. Nursing staff failed to accompany Patient 1 while she was acting out (setting off the fire alarm) and "running" down the hallway. Per policy, the patient should not have been left unattended during these activities that put her at increased risk of falling. She further stated that following the fall, Patient 1 refused to allow vital signs and she "acted like her leg hurt, but there was not anything physical that we could see". When we got her up we walked her about 4 feet to her bed. "We performed an assessment including her leg, however without removing her pants all the way but could see her hip."

Review of the "ARF Score Sheet" showed Staff I reassessed Patient1's fall risk on 03/15/20 at an undocumented time with a score of 15 and Staff H, DON reassessed Patient 1's fall risk again on 03/15/20 at an undocumented time with a score of 20. Nursing Staff failed to time the entries into the medical record.

Review of the "Multi-Disciplinary Note," dated 03/15/20 at 6:15 PM by Staff F RN, showed, Patient 1 "Put self on floor and c/o (complained of) right lower extremity (RLE) pain. Order for two view X-ray obtained." The medical record lacked documentation that Staff F, RN transcribed a physician's order for the X-rays of Patient 1 when she notified Staff K, Doctor of Osteopathy (DO) of the patient's fall on 03/15/20 at 6:30 PM. The medical record failed to contain any documentation of the information that Staff F, RN shared with Staff K, DO about Patient 1's condition after her fall.

During an interview on 03/18/20 at 4:00 PM, Staff F, RN said she was at the desk on 03/15/20 when Patient 1 fell , but she did not see her fall. She stated, "I heard Patient 1 say, "I'm falling" and by the time I stood up she was on the floor on her left side." Patient 1 immediately complained of right leg pain. She then stated the three-staff helped her up and got her into bed. Patient 1 did not bear weight on the right. Staff F, RN stated vital signs were stable and the patient was assessed. Patient 1 was unable to describe the pain. The assessment showed she had external rotation, no shortening, and was able to pull her knee up a little bit. She was combative and aggressive. Staff F stated that she notified Staff K, DO of the fall and he ordered an X-ray. Staff F, RN said that there was no discussion with Staff K, DO regarding sending Patient 1 to the hospital nor was anything ordered for pain. Patient 1 had a standing prn order for Tylenol. She stated she called the mobile X-ray company after she received the order from Staff K. She then stated, "It is my understanding that X-ray did not come out until the next day." Patient 1 did complain of pain, but only when she was moved. Staff F further stated during her post fall assessment she was able to localize the pain to the right leg and the "leg was definitely rotated out". She then stated she told Staff K, DO that the leg had slight rotation out, some shortening, and she was in pain.

Review of the hospital policy titled, "Patient Fall Risk", revised 12/16 showed, ... "The ...Psychiatrist will be contacted by the charge nurse to determine the course of treatment after the patient has fallen".

Review of the hospital policy titled, "Incident Report", revised 12/16, showed, ... "Incident reports are a confidential document for facility use only."

The medical record lacked any evidence that Staff F notified the physician of Patient 1's inability to bear weight on her right leg and that the patient had 10/10 sharp, constant pain. Her documentation of 10/10 pain on the "Post Fall Assessment" contradicts her interview statement that Patient 1 was unable to describe the pain. Per interview, the patient's right leg had slight rotation out and some shortening (displaced fractures of the femoral neck will classically cause external rotation and shortening of the leg when the patient is laying supine). The medical record lacked any evidence that Patient 1 had external rotation and shortening. The "Incident/Accident Report" contained one set of vital signs, however, this document is not part of the patient's medical record. The medical record lacked documentation that Staff F or any other nursing staff contacted the Psychiatrist after Patient 1's fall per policy. The medical record failed to contain any documentation Staff F or any other nursing staff notified the mobile X-ray company after nursing staff received the order for the portable X-ray on 03/15/20 at 6:30 PM.

During an interview on 03/23/20 at 10:46 AM, Staff H, DON stated that she was at the facility the day Patient 1 fell . She stated that she did not do an assessment but did see the presence of leg swelling. She instructed the nurse (Staff F) to contact the physician and have Patient 1 sent to the emergency department (ED). The nurse called Staff K, DO who ordered a portable X-ray instead. Staff H stated that if a nurse does not agree with a physician's order they are to call the DON or the administrator on call (AOC).

Review of the hospital policy titled, "Post Fall Process", revised on 3/17, showed, "In the event that a patient experiences a fall, the following process will be followed: medical care provided if injury is sustained and under the orders of the physician; the Post Fall Assessment Form will be completed after a patient has fallen; and notification to the DON."

Review of the document titled, "Post Fall Assessment", completed by Staff F, RN on 03/15/20 at 6:45 PM showed vital signs and neurological assessment should be completed every 15 minutes times two, every 30 minutes times two, every hour times two, and every four hours times two following a fall. Nursing staff (Staff F, Staff I, or any other nurse) did not complete any vital signs on this form and completed only two sets of untimed vital signs on the "Graphics/Vital Signs Flowsheet" on 03/15/20. Nursing Staff F documented only one neurological assessment on the form on 03/15/20. Staff F, Staff I, or any other nurse failed to document or assess Patient 1's neurological status any further on the "Post Fall Assessment" for the 7.5 hours following Patient 1's fall. Staff F, RN further documented on the "Post Fall Assessment" form that Patient 1 had decreased range of motion of her RLE, a pain level rated 10 out of 10 (0 no pain, 10 worse pain), described as sharp and constant. The medical record lacked any evidence that Staff F or any other nursing staff administered any pain medication to Patient 1 at the time of the fall for her c/o 10/10, sharp, constant pain or obtained a physician's order for any stronger pain medication than the Tylenol Patient 1 already had ordered at admission. The medical record lacked any evidence that Staff F notified the physician of the external rotation of Patient 1's RLE which is a sign of a femur fracture. Staff F and Staff I failed to fill out the "Post Fall Assessment" form completely per policy.

Nursing staff failed to fill out the "RN Post Fall Screen for Fall Precautions" completely and accurately. Nursing staff failed to mark "Yes" or "No" to the question about the use of assisted [sic] devices. Nursing staff failed to indicate that Patient 1 used a walker as documented on nursing assessment. Nursing staff failed to mark "Yes" or "No" to the question about over sedation. Nursing staff failed to mark "Yes" or "No" to the question about Blood pressure (BP) (orthostatic hypotension) although "Lying" is checked and a BP of 112/58 was documented on the line labeled, Irregular pulse rate. Nursing staff failed to mark "Yes" or "No" to the question about Irregular pulse rate and there is no other number documented on the form to indicate Patient 1's pulse. Nursing staff failed to circle either "Mild", "Moderate", or "High" on the question about fall "Level Identified". Nursing failed to mark "Yes" or "No" to the question about whether "Interventions changed on treatment plan".

Review of the document titled, "Fall Analysis Form," showed, Staff G, RN indicated the fall was not medication related, but was related to the patient's mental health. She further document X-rays were ordered, and the activities/processes occurring at the time of the fall could cause the fall. Staff H, DON did not sign the document even though she indicated that she was present at the facility the day Patient 1 fell and Staff F, Staff I or any other nursing staff failed to document notification of the Patient 1's fall to the DON.

Nursing Staff failed to fill out the "Fall Analysis Form" dated 03/15/20 completely and correctly. Nursing Staff documented Patient 1 was identified as a fall risk on admission but marked "NA" (not applicable) to the question, "Was the Fall Risk Protocol implemented and documented after admit/prior to fall?". Nursing staff marked "NA" to the question "Were any environmental factors involved in this event?" Even though, the next line asks the recorder to "Please identify the environmental factor" and the nursing staff documented, "Turning on fire alarm." Nursing staff marked both "Yes" and "No" to the question, "Was staffing adequate according to grid?". Nursing staff marked "Yes" to the question, "Activities/processes occurring at this time that could be factors in cause of this event?" However, nursing staff failed to identify what activity/process was a factor in Patient 1's fall.

Review of the hospital policy titled, "Incident Report", revised 12/16, showed, ... "All sections of the Incident report must be completed."

Nursing staff failed to fill out the "Incident/Accident Report" dated 03/15/20 completely. Nursing staff failed to complete the section of the report asking for "Previous Fall Score and New Fall Score".

Staff I, RN documented on a "Nursing Daily Note" on 03/15/20 at 10:00 PM that Patient 1 had a complaint of (c/o) pain 10/10 of her RLE when the nurse administered her night time medications and so she gave Patient 1 650 mg (milligrams) of Tylenol (APAP - analgesic that treats mild aches and pains) at 9:05 PM (about 2 hours and 50 minutes after the fall). Staff I, RN indicated the APAP was ineffective and she called the doctor and received an order for the narcotic pain medication, Norco. The record showed that nursing staff administered Norco at 10:35 PM and that Patient 1 fell asleep.

During a telephone interview with Staff I, Agency RN on 03/19/20 at 10:17 AM, she stated that the night Patient 1 fell during the prior shift, Staff F had obtained an order for an X-ray from Staff K, DO but it was not a STAT order. After report, she stated Patient 1 was in bed and not complaining of pain at that time. Staff I, RN stated later into the shift Patient 1 started complaining of pain and I gave her Tylenol which seemed to relieve the pain until 10:00 to 10:30 PM when the pain became worse. She stated she contacted Staff K, DO who gave an order for Norco which I gave Patient 1 every four hours during the night. At some point, she stated the mobile X-ray company called stating they would not be available to do the X-rays until midnight and Staff I, RN told them to wait until morning because the patient was sleeping. She stated she gave that information to Staff K, DO when she called for the pain medication order. He told her if the pain medication did not keep her comfortable to call him again and he would send her to the ED. Because the pain was relieved she did not call the doctor back. She stated staff repositioned her several times during the shift and she remained comfortable. During the night chart audit, she stated that she did not see the order for Patient 1's mobile X-ray.

Additionally, the medical record showed that Staff I, RN administered Norco on 3/16/20 at 2:30 AM for c/o 10/10 pain in the RLE and on 3/16/20 at 6:30 AM for c/o 10/10 pain in the RLE.

The medical record lacked evidence that Staff I obtained an order from Staff K, DO to hold the X-ray until the morning. After she conducted the night chart audit and found the order for Patient 1's X-rays missing, Staff I failed to obtain an order for the X-ray from Staff K, DO that had not been transcribed by Staff F, RN.

The medical record showed that Staff E, Agency RN administered Norco on 3/16/20 at 11:15 AM for c/o 10/10 pain in the RLE. The medical record lacked evidence that Staff E assessed or documented Patient 1's response to pain medication administered on 03/16/20 at 11:15 AM.

The medical record showed an order for an X-ray of Patient 1's right hip and right upper leg on 03/16/20 at 1:30 PM (around 19 hours after the fall) and Staff E failed to write the order as STAT. The mobile X-ray company performed Patient 1's X-rays on 03/16/20 at 1:43 PM (around 19.5 hours after the fall).

Documentation from the mobile X-ray company showed they arrived at the hospital on [DATE] at 1:43 PM and performed an X-ray of both hips and the right femur. Their clinical note showed a right femoral neck fracture and the results were called to nursing staff at the hospital on [DATE] at 3:30 PM.

The medical record failed to indicate whether the order received by the nursing staff on 03/16/20 at 1:30 PM for a straight cath (catheter) (used to take a sample of urine from a patient, meant for temporary use and is removed and disposed of or sterilized immediately afterwards), urinalysis with culture and sensitivity, and X-ray to right hip and right upper leg was a telephone or verbal order, the name of the Doctor who gave the order, and a read back verification of the order. The order did contain Staff K, DO's undated, untimed signature.

The medical record showed that Patient 1 transferred to a local acute care hospital's (hospital B's) emergency department (ED) on 03/16/20 at 4:30 PM (around 22 hours after the fall) for treatment of a right femoral neck fracture.

Medical record from the acute care hospital B showed that Patient 1 had surgical repair of the right hip on 03/17/20.

During an interview on 03/18/20 at 6:30 PM, Staff E, Agency RN, stated she has worked at this facility for two weeks. She stated she worked the nursing desk on 03/16/20 starting at 7:00 AM. She performed an assessment of Patient 1 and saw the right leg rotated out and 3 inches shorter than the left with minimal bruising. She was told in report that Patient 1 had fallen the evening before. She stated she called the mobile X-ray company to ask about an expected time of arrival to perform Patient 1's X-rays and was told it "would be pretty soon." She further stated that she called Staff K, DO and he did not answer. She stated that she didn't remember what time she made the first call. She called Staff K, DO for a second time on 03/16/20 at 10:34 AM and told him the X-ray had not been performed, gave him the results of her assessment, and he made the decision to wait to transfer Patient 1 to the ED until after the X-ray results were available. Staff E, RN stated that she was unable to find the original X-ray order, so she wrote the order and called the mobile X-ray company again at 12:20 PM. Mobile X-ray arrived shortly after the last phone call and the results of fractured femur were reported. Staff K, DO came into the facility at some time around the time the mobile X-ray company came. He signed the order but did not assess the patient. Staff E, RN stated she reported her assessment to Staff H, DON including her belief Patient 1 had a RLE displacement or fracture and Staff K, DO refused to send her to the hospital prior to the X-ray. "I do not know if Staff H, DON assessed Patient 1, but I do know she was aware I had called X-ray a couple of times."

The medical record lacked documentation that Staff E notified Staff K, DO of the X-ray results on 03/16/20. The medical record lacked evidence of documentation that Staff E transcribed Patient 1's transfer order to the acute care hospital on [DATE]. The medical record lacked evidence that Staff E documented vital signs on the "Graphics/Vital Signs Flowsheet" on 03/16/20. The medical record lacked evidence of nursing assessment or documentation of fifteen-minute checks on the "Close Observation Sheet" on 03/16/20.

The medical record lacked evidence of the phone calls Staff E made to the mobile X-ray company or the requests or inquiries made on 03/16/20. The medical record lacked evidence that Staff E, RN documented the conversations she had with the DON expressing concerns about Patient 1's care (information obtained by interview): She said that she assessed Patient 1 and her leg was rolled out and was 3" shorter. She had only minimal bruising. She stated that she called the Physician and he did not answer (didn't recall the time of the first call) and so she called back at 10:34 AM and told him X-ray had not come out and gave him the results of her assessment, asking if Patient 1 could transfer to the hospital. She stated that he said to wait to transfer the patient until after the X-ray. Nursing staff called the mobile X-ray company around 12:20 PM and changed the priority of the X-ray to STAT. The nursing staff said that she had a couple of conversations with the Director of Nursing (DON) regarding concerns about Patient 1's injury and waiting for the portable X-ray instead of transferring the patient to the local acute care hospital. The medical record lacked documentation of these conversations and there was no documentation in the medical record indicating that the DON reviewed the situation or took any actions on behalf of Patient 1.

During a telephone interview on 03/19/20 at 8:13 AM, Staff J, Supervisor of the contracted mobile X-ray company, stated Staff X, Receptionist received orders from a staff RN at the hospital for a right hip and right femur X-ray post fall per Staff K, DO on 03/15/20 at 6:43 PM. The order was not flagged as STAT (immediately). On 03/15/20 at 10:23 PM, X-ray technician Staff Y documented the X-ray would be rescheduled for 03/16/20 per a hospital nurse. Further documentation by dispatcher Staff Z showed that a hospital nurse called on 03/16/20 and asked if the X-ray was going to be done this morning. At that time, the order was changed to STAT. Staff Z sent a message to an X-ray technician at 12:33 PM requesting an estimated time of arrival. The X-ray was taken at 2:02 PM. The results showing a right femoral neck fracture were faxed on 03/16/20 at 2:25 PM to the hospital and we also notified the hospital nurse by telephone.

During telephone interview on 03/19/2020 at 7:38 AM, Staff K, DO, stated he did not remember what day or time he was called about Patient 1 following her fall, but remembered getting a call from a nurse and giving an order for a portable X-ray. He stated the decision to not send her to the ED for an evaluation was based on the nursing assessment given to him over the phone. The RN giving the report did not suspect a fracture. He stated he received a second call at an unknown date or time by a nurse with a report that the X-ray had been completed and he thought she was transported to the ED prior to being seen by him or one of his mid-levels. Staff K, DO had no recall of being at the hospital on [DATE] or of giving orders for additional pain medication during the night. Staff K, DO stated he depends on the nursing assessment to help make his medical decisions.

During a second interview on 03/23/20 at 1:22 PM, Staff K stated he told the nurse to send Patient 1 to the ED and the nurse offered a mobile X-ray first and he agreed. He clarified the X-ray was not ordered STAT, but just to be done the same day, but sometime on 03/16/20 staff called and told him the X-ray was not done. Staff K reviewed the orders for Patient 1 and verified there was not a physician's order written by nursing as a telephone order for the X-ray he requested on 03/15/20. He was notified by a nurse "at some time" that her (Patient 1's) leg was rotated and shortened but did not recall when he received the information.

During an interview on 03/18/20 at 4:48 PM, Staff H, DON stated that she spoke with Staff K, DO regarding Patient 1's X-ray orders and the delay in obtaining the X-rays. He told her the initial X-ray was ordered STAT (immediately). He further told her X-r
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, document review, medical record review, personnel record review and policy review the Governing Body failed to ensure the medical staff is accountable for the quality of care provided to patients, failed to ensure the Director of Nursing (DON) was competent to oversee the nursing care provided to patients, that nursing staff received sufficient and complete orientation, training and education related to specialty psychiatric patients with documented competencies, failed to ensure nursing staff followed policy and procedure for documenting orders, patient assessments, communication and completion of all medical record forms, and failed to ensure education, oversite, and implementation of the COVID-19 infection control plan.

The cumulative effect of the Governing Body's failure to ensure the medical staff are accountable for the quality of care provided to patients, the DON is competent to oversee nursing staff and provide sufficient orientation, training and education for staff to ensure policies and procedures of the hospital are followed and the failure to ensure education, oversite, and implementation of the COVID-19 infection control plan, has the potential to place patients and staff at risk of infection, substandard care, worsening of conditions, illness or even death.


Findings Include:

Review of the hospital's Governing Body and Medical Staff Bylaws showed the governing body retains ultimate authority for the quality of patient care rendered in the hospital and the medical staff are to account for the quality and appropriateness of patient care rendered by all Practitioners who provide patient care services.

The hospital failed to ensure the governing body provided oversight of the medical staff for the quality of care provided to patients, and the medical staff failed to examine and assess a patient (Patient 1) who sustained a severe injury (hip fracture) that resulted in the need to transfer to another hospital for a higher level of care and services. (Refer to A0049).

The hospital failed to ensure the Director of Nursing (DON) was competent to oversee the nursing staff, nursing care provided to patients, that nursing staff received sufficient and complete orientation and education related to psychiatric patients with documented competencies, and failed to ensure nursing staff followed policies and procedures, documented all orders, assessments, communication and completed all medical record forms.
The cumulative effect of the hospital's failure to ensure the DON is competent to oversee nursing staff, the nursing care provided to patients, that nursing staff received sufficient and complete orientation and education 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). The hospital administration was notified of the IJ on 03/23/20 at 2:16 PM. The hospital submitted a plan of removal that was not credible on 03/23/20 at 4:20 PM and was asked to revise the plan of removal. The hospital submitted a second plan of removal on 03/24/20 at 11:36 AM which was not credible and so an IJ related to 42 CFR 482.23, requirements for Nursing Services remains in place at the survey exit on 03/25/20. (Refer to A-0385)

The hospital failed to ensure the DON took responsibility for overseeing the orientation of hospital and agency staff and failed to ensure the quality of patient care provided by the staff. The DON failed to complete the responsibilities of her job description including: being responsible for hiring, training and supervising hospital nursing staff; being responsible for upholding the standards of care established by regulatory and accrediting bodies; being responsible for providing assistance as needed to the nursing staff with regard to decision making, clinical judgment issues; medical staff communication; being responsible for coordinating the performance of nursing care within the scope of practice and in compliance with policies, procedures, and standards; beinr responsible for ensuring survey readiness through regulatory compliance and quality standards of care; being responsible for performing additional tasks as assigned by the Administrator and being responsible to ensure patients' needs are met and hospital policies are followed in nursing services. (Refer to A-0386).

The hospital nursing staff failed to assess, evaluate, and perform interventions in a timely manner for one (Patient 1) of three medical records reviewed after a fall resulting in an obvious injury and for one (Patient 3) of three fall patients reviewed with a minor injury. The medical record failed to show evidence nursing staff assessed the patient as directed per protocol following a fall, failed to document verbal physician orders when received, failed to document communication to the physician, failed to document communication with outside agencies, failed to notify the physician of changes in the patient's status, failed to document communication of test results to the physician, and failed to document communication of the fall to the Director of Nursing (DON). (Refer to A-0395).

The DON and the hospital failed to ensure all nursing staff received appropriate orientation and competency assessments necessary to provide safe, effective care for 4 of 4 nursing staff reviewed (Staff E, agency registered nurse (RN), Staff G, agency RN, Staff F, hospital RN, and Staff H, RN, Director of Nursing [DON]) in a psychiatric hospital. (Refer to A-0397).

The DON and the hospital failed to ensure agency and hospital nurses were oriented to all policies and procedures prior to providing care for four of four personnel records reviewed (Staff E, F, G and H) and per interview with Staff N, Agency RN, and failed to ensure policy and procedures were followed by nursing staff related to falls, nursing documentation and physician orders for two of two patients with falls (Patients 1 and 3). (Refer to A-0398).

Review of Staff H, Director of Nursing's, (DON) personnel file lacked evidence of documented education related to the national standards of infection prevention and control or evidence she had completed training for the role of Infection Preventionist. Staff H's personnel file also lacked documented evidence of her appointment by the governing body as the hospital's Infection Preventionist. Staff H was unable to provide documented evidence of Infection control training with the corporate trainer and/or a course that she took in another state or that she was qualified through education, training, experience, or certification in infection prevention and control. (Refer to A-0748).

The Governing Body failed to ensure the Infection Preventionist maintained the implementation of the system for tracking infection surveillance, prevention and control and demonstrated success and sustainability of the COVID-19 infection control program. Governing Body By-Laws lacked documented evidence of their responsibility to appoint an Infection Preventionist. (Refer to Tag A-0770).

The hospital failed to ensure the Infection Preventionist developed and implemented hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines for COVID-19. (Refer to Tag A-0772).

The Infection Preventionist failed to provide COVID-19 competency-based infection control training for all facility staff, patients, providers, and contracted staff. (Refer to Tag A-775).
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and document review the hospital failed to ensure the governing body provided oversight of the medical staff for the quality of care provided to patients, and the medical staff failed to examine and assess a patient (Patient 1) who sustained a severe injury (hip fracture) that resulted in the need to transfer to another hospital for a higher level of care and services. Failure of the governing body to provide oversight of the medical staff for the quality of care provided to patients and failure of the medical staff to exam and assess a patient following a significant injury places all patients at risk for inadequate medical care resulting in harm, further injury, ongoing pain, or death.

Findings Include:

Review of the hospital's undated document titled, "Governing Body By-Laws," showed ...the governing body shall have charge of maintenance and operation of the hospital and shall continually study and investigate the health needs of the community served ...the governing body retains ultimate authority for the quality of patient care rendered in the hospital ... ...The Governing Body Shall hold the Medical Staff and other professionals providing patient care services accountable for conducting activities that contribute to the preservation and improvement of the quality and efficiency of patient care provided in the hospital.

Review of the hospital's undated document titled, "Medical and Professional Staff Organization Bylaws," showed the responsibilities of the Medical Staff are to account for the quality and appropriateness of patient care rendered by all Practitioners and Allied Professionals authorized to provide patient care services in the hospital ... ...Provide his patients with care at the profession level of quality and efficiency as defined by the Medical Staff (PAW - Practitioners as a Whole) and Governing Body: ...


Patient 1


Review of Patient 1's medical record showed she was [AGE] year-old female with a voluntary admission on 03/11/20 with diagnoses of [DIAGNOSES REDACTED][DIAGNOSES REDACTED] (under active thyroid), and congestive heart failure (CHF) (inability of the heart to pump blood properly).

The medical record showed that she fell on [DATE] at 6:15 PM and complained of right lower extremity (RLE) pain. An order for two view X-rays was obtained but there was no documented evidence in the physician's orders that an order was written. At 9:05 PM on 03/15/20, Patient 1 was given Acetaminophen (Tylenol) 650 milligrams (mg) for complaints of RLE pain. At 10:00 PM on 03/15/20, the nurse indicated that the acetaminophen was ineffective, Staff K, Doctor of Osteopathic Medicine (DO) was called, and he gave an order for Norco (narcotic pain medication). The medical record showed that Patient 1 was given Norco at 10:35 PM on 03/15/20, and nursing staff continued to give her the Norco approximately every four hours for pain that was rated 10 out of 10. (Zero = no pain and 10 being the worst pain). The nurse also documented that mobile X-ray company was to see Patient 1 in the morning.

During an interview on 03/18/20 at 4:00 PM, Staff F, RN said she was at the desk on 03/15/20 when Patient 1 fell , but she did not see her fall. She stated, "I heard Patient 1 say, "I'm falling" and by the time I stood up she was on the floor on her left side." Patient 1 immediately complained of right leg pain. She then stated the three-staff helped her up and got her into bed. Patient 1 did not bear weight on the right. Staff F, RN stated vital signs were stable and the patient was assessed. Patient 1 was unable to describe the pain. The assessment showed she had external rotation, no shortening, and was able to pull her knee up a little bit. She was combative and aggressive. Staff F stated that she notified Staff K, DO of the fall and he ordered an X-ray. Staff F, RN said that there was no discussion with Staff K, DO regarding sending Patient 1 to the hospital nor was anything ordered for pain. Patient 1 had a standing prn order for Tylenol. She stated she called the mobile X-ray company after she received the order from Staff K. She then stated, "It is my understanding that X-ray did not come out until the next day." Patient 1 did complain of pain, but only when she was moved. Staff F further stated during her post fall assessment she was able to localize the pain to the right leg and the "leg was definitely rotated out". She then stated she told Staff K, DO that the leg had slight rotation out, some shortening, and she was in pain (displaced fractures of the trochanter (the upper part of the thigh bone) or femoral neck will typically cause external rotation and shortening of the leg).

During an interview on 03/18/20 at 6:30 PM, Staff E, Agency RN, who worked on 03/16/20 starting at 7:00 AM, stated that she performed an assessment of Patient 1 and saw the right leg rotated out and 3" shorter than the left with minimal bruising. She stated she called the mobile X-ray company to ask about an expected time of arrival to perform the X-ray and was told it "would be pretty soon." She stated she called Staff K, DO at an undocumented time and he did not answer. She called again at 10:34 AM on 03/16/20 and told him the X-ray had not been performed, gave him the results of her assessment, and he made the decision to wait for the mobile X-ray to make a decision about transferring the patient to an acute care hospital. She also stated she was unable to find the original X-ray order, so she wrote the order and called the portable X-ray provider again at 12:20 PM. Staff E stated that Staff K, DO came into the facility at some point around the time the mobile X-ray arrived. He signed the order but did not assess the patient, however he did perform weekly assessments on several other patients while in the facility.

Review of current medical records of patients who were seen by Staff K, DO, on 03/16/20, showed he was in the facility and saw four patients, Patient 6 at 1:00 PM, Patient 8 at 1:15 PM, Patient 7 at 1:20 PM and Patient 13 at 1:30 PM. There was no documented evidence that Staff K, examined or assessed Patient 1 while he was at the hospital.

Patient 1 was X-rayed at 1:43 PM on 03/16/20, the X-ray showed she had fractured her right femoral neck (hip fracture) and was transferred to the hospital at 4:30 PM by Emergency Medical Services..

During a telephone interview on 03/19/20 at 7:38 AM, Staff K, DO, stated that he could not remember the date or time but that he did remember getting a call from a nurse, and that he gave an order for a portable X-ray instead of sending the patient to the emergency department (ED) in response to the evaluation he was given by the nurse. Staff K, DO stated that he was called a second time, but could not remember the date or the time, with the X-ray results and he thought Patient 1 had gone to the hospital before he or his two Advanced Practice Registered Nurses (APRN) got to the facility to see patients. Staff K stated that he did not remember being at the facility on Monday 03/16/20 (the day after the patient fell ). He also did not remember anyone calling him the night of 03/15/20 about Patient 1 having pain.

During an additional interview on 03/23/20 at 1:22 PM, Staff K, DO stated that he did not assess Patient 1 on Monday 03/16/20 when he came to the facility. He stated he only saw half of the patient's and she was not one of them. Staff K stated that he recalled Patient 1 had fallen on Sunday the day before, but he was not sure of the time and "he remembered the nurse was not impressed with the patient being in pain." Staff K stated that he told the nurse to send the patient to the ED and the nurse offered a mobile X-ray and he agreed. Staff K, further stated that he did not look for x-ray results on Monday when he was at the facility. Staff K stated that the nursing staff are responsible for who he assesses when he is in the facility and if they do not bring it to his attention it will not get done.

During an interview on 03/23/20 at 10:46 AM, Staff H, DON stated if a nurse does not agree with a physician's order they are to call the DON or the administrator on call (AOC). Patient 1 fell on Sunday 03/15/20 and Staff H stated that she was at the facility. She stated that she instructed the nurse to contact the physician and have Patient 1 sent to the emergency department (ED). Staff H, DON also stated she was unaware Staff K, DO was in the building the next day, Monday 03/16/20 and stated since he was in the building her expectation would be that he should have assessed Patient 1.

During an interview on 03/23/20 at 11:05 AM, Staff L, CEO stated that someone from administration is always on call 24/7. Staff L stated he was unaware Staff K, DO refused to send Patient 1 to the hospital to obtain the X-ray, he was not aware of the delay in obtaining the X-ray, and was not aware Staff K was in the facility on Monday following the fall and that Staff K did not assess Patient 1.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview, record review, document review, and policy review the hospital failed to ensure the Director of Nursing (DON) was competent to oversee the nursing staff, nursing care provided to patients, that nursing staff received sufficient and complete orientation and education related to psychiatric patients with documented competencies, and failed to ensure nursing staff followed policies and procedures, documented all orders, assessments, communication and completed all medical record forms.

The cumulative effect of the hospital's failure to ensure the DON is competent to oversee nursing staff, the nursing care provided to patients, that nursing staff received sufficient and complete orientation and education 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). The survey team notified hospital administration on 03/23/20 at 2:16 PM that an IJ had been identified related to 42 CFR 482.23, requirements for the condition of particiption of Nursing Services.

On 03/23/20 at 4:20 PM hospital staff submitted a plan of removal for the IJ. The survey team notified hospital staff at 5:05 PM that the submitted plan of removal for the IJ was not credible. The hospital Administration was notified additional information related to the plan of removal would need to be submitted.

The hospital submitted a second plan of correction on 03/24/20 at 11:36 AM.

During the exit conference on 03/25/20 at 12:30 PM, the State Agency (SA) notified the hospital that the second plan of removal was not credible and the IJ finding remained in place at the survey exit.


Findings Include:


The hospital failed to ensure the DON took responsibility for overseeing the orientation of hospital and agency staff and failed to ensure the quality of patient care provided by the staff. The DON failed to complete the responsibilities of her job description including: being responsible for hiring, training and supervising hospital nursing staff; being responsible for upholding the standards of care established by regulatory and accrediting bodies; being responsible for providing assistance as needed to the nursing staff with regard to decision making, clinical judgment issues; medical staff communication; being responsible for coordinating the performance of nursing care within the scope of practice and in compliance with policies, procedures, and standards; beinr responsible for ensuring survey readiness through regulatory compliance and quality standards of care; being responsible for performing additional tasks as assigned by the Administrator and being responsible to ensure patients' needs are met and hospital policies are followed in nursing services. (Refer to A-0386).

The hospital nursing staff failed to assess, evaluate, and perform interventions in a timely manner for one (Patient 1) of three medical records reviewed after a fall resulting in an obvious injury and for one (Patient 3) of three fall patients reviewed with a minor injury. The medical record failed to show evidence nursing staff assessed the patient as directed per protocol following a fall, failed to document verbal physician orders when received, failed to document communication to the physician, failed to document communication with outside agencies, failed to notify the physician of changes in the patient's status, failed to document communication of test results to the physician, and failed to document communication of the fall to the Director of Nursing (DON). (Refer to A-0395).

The DON and the hospital failed to ensure all nursing staff received appropriate orientation and competency assessments necessary to provide safe, effective care for 4 of 4 nursing staff reviewed (Staff E, agency registered nurse (RN), Staff G, agency RN, Staff F, hospital RN, and Staff H, RN, Director of Nursing [DON]) in a psychiatric hospital. (Refer to A-0397).

The DON and the hospital failed to ensure agency and hospital nurses were oriented to all policies and procedures prior to providing care for four of four personnel records reviewed (Staff E, F, G and H) and per interview with Staff N, Agency RN, and failed to ensure policy and procedures were followed by nursing staff related to falls, nursing documentation and physician orders for two of two patients with falls (Patients 1 and 3). (Refer to A-0398).
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on interview, medical record review, and document review the hospital failed to ensure the Director of Nursing (DON) took responsibility for overseeing the orientation of hospital and agency staff and failed to ensure the quality of patient care provided by the staff. The DON failed to complete the responsibilities of her job description including: being responsible for hiring, training and supervising hospital nursing staff; being responsible for upholding the standards of care established by regulatory and accrediting bodies; being responsible for providing assistance as needed to the nursing staff with regard to decision making, clinical judgment issues; medical staff communication; being responsible for coordinating the performance of nursing care within the scope of practice and in compliance with policies, procedures, and standards; being responsible for ensuring survey readiness through regulatory compliance and quality standards of care; being responsible for performing additional tasks as assigned by the Administrator (Infection Control Preventionist) and being responsible to ensure patients' needs are met and hospital policies are followed in nursing services.

Failure of the DON to ensure staff are trained and competent resulted in hospital and agency nursing staff receiving inadequate or no training during orientation and allowing staff with no background in psychiatric nursing routinely care for the hospital's patients. Failure of the DON placed all patients at risk for poor quality nursing care provided by inadequately trained nursing staff including failure to assess, advocate, follow policies and procedures, and intervene on a patient's behalf.


Findings Include:

Review of undated document titled, "Vendor Orientation", stated the purpose of orientation is to provide "a short, concise orientation to major factors that drive our facility and the care of our patients. This allows a means to ensure the safety of all involved ...Safety is an integral requirement in the deliver of high quality health care ..."

Document review of hospital Committee Meeting Minutes reported 02/13/20 at 1:00 PM showed under safety training acknowledgements were sent out to all nurses and the DON would follow up with each RN to ensure understanding of all areas requiring improvement. The DON failed to provide documentation of review and follow up with the RNs.

Review of the job description for the hospital DON revised on 10-01-17 showed, "Position Summary: The Director of Nursing is responsible for upholding the standards of care established by regulatory and accrediting bodies. The Director of Nursing provides oversight and direction to all direct care nursing staff. The DON ensures the unit is staffed safely and according to protocol; providing assistance as needed to the nursing staff with regard to decision making, clinical judgment issues; medical staff communication; as well as providing direct patient care when indicated ...Coordinates the performance of nursing care within the scope of practice and in compliance with policies, procedures, and standards ...The DON is charged with ensuring survey readiness through regulatory compliance and quality standards of care ...Duties and responsibilities: 1. Responsible for the leadership and professional development of the nursing staff. 10. Implements an effective, ongoing program to measure, assess, and improve the quality of nursing care delivered to patients. 21. Performs additional tasks as assigned by the Administrator. 47. Ensure patients' needs are met and hospital policies are followed in nursing services.


The hospital failed to ensure the Director of Nursing (DON) was competent to oversee the nursing staff, nursing care provided to patients, that nursing staff received sufficient and complete orientation and education related to psychiatric patients with documented competencies, and failed to ensure nursing staff followed policies and procedures, documented all orders, assessments, communication and completed all medical record forms.

The cumulative effect of the hospital's failure to ensure the DON is competent to oversee nursing staff, the nursing care provided to patients, that nursing staff received sufficient and complete orientation and education 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). The survey team notified hospital administration on 03/23/20 at 2:16 PM that an IJ had been identified related to 42 CFR 482.23, requirements for the condition of particiption of Nursing Services.

On 03/23/20 at 4:20 PM hospital staff submitted a plan of removal for the IJ. The survey team notified hospital staff at 5:05 PM that the submitted plan of removal for the IJ was not credible. The hospital Administration was notified additional information related to the plan of removal would need to be submitted.

The hospital submitted a second plan of correction on 03/24/20 at 11:36 AM.

During the exit conference on 03/25/20 at 12:30 PM, the State Agency (SA) notified the hospital that the second plan of removal was not credible and the IJ finding remained in place at the survey exit. (Refer to A-0385).


The hospital nursing staff failed to assess, evaluate, and perform interventions in a timely manner for one (Patient 1) of three medical records reviewed after a fall resulting in an obvious injury and for one (Patient 3) of three fall patients reviewed with a minor injury. The medical record failed to show evidence nursing staff assessed the patient as directed per protocol following a fall, failed to document verbal physician orders when received, failed to document communication to the physician, failed to document communication with outside agencies, failed to notify the physician of changes in the patient's status, failed to document communication of test results to the physician, and failed to document communication of the fall to the Director of Nursing (DON). (Refer to A-0395).


The DON and the hospital failed to ensure all nursing staff received appropriate orientation and competency assessments necessary to provide safe, effective care for 4 of 4 nursing staff reviewed (Staff E, agency registered nurse (RN), Staff G, agency RN, Staff F, hospital RN, and Staff H, RN, Director of Nursing [DON]) in a psychiatric hospital. (Refer to A-0397).


The DON and the hospital failed to ensure agency and hospital nurses were oriented to all policies and procedures prior to providing care for four of four personnel records reviewed (Staff E, F, G and H) and per interview with Staff N, Agency RN, and failed to ensure policy and procedures were followed by nursing staff related to falls, nursing documentation and physician orders for two of two patients with falls (Patients 1 and 3). (Refer to A-0398).


Document review of the undated hospital policy titled "IC-1016: Infection Prevention and Control Plan" showed administration was responsible for appointing an infection preventionist who is responsible for prioritizing risks, setting goals and measurable objectives, establishing activities based on the goals and objectives using evidence-based national guidelines or expert consensus when developing the prevention activities.

Review of Staff H's, Director of Nursing, (DON) personnel file lacked evidence of documented education related to the national standards of infection prevention and control or evidence she had completed training for the role of Infection Preventionist. Staff H's personnel file also lacked documented evidence of her appointment by the governing body as the hospital Infection Preventionist.

During an interview on 03/24/20 at 3:18 PM, Staff H, DON stated that she was appointed the Infection Preventionist in 06/2019 and that her training was with corporate and a meeting in another state.

Staff H was unable to provide documented evidence of infection control training with corporate and a meeting in another state or that she was qualified through education, training, experience, or certification in infection prevention and control. (Refer to A-0748).

The Governing Body failed to ensure the Infection Preventionist maintained the implementation of the system for tracking infection surveillance, prevention and control and demonstrated success and sustainability of the COVID-19 infection control program. (Refer to Tag A-0770).
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, document review, and policy review the hospital nursing staff failed to assess, evaluate, and perform interventions in a timely manner for one (Patient 1) of three medical records reviewed after a fall resulting in a serious (right hip fracture) and for one (Patient 3) of three fall patients with a minor injury (swelling and bruising). The medical record failed to show evidence nursing staff assessed the patient as directed per protocol following a fall, failed to document verbal physician orders when received, failed to document communication to the physician, failed to document communication with outside agencies, failed to notify the physician of changes in the patient's status, failed to document communication of test results to the physician, and failed to document communication of the fall to the Director of Nursing (DON).

Failure of nursing staff to assess, advocate, follow policies and procedures, and intervene on the patient's behalf in a timely manner resulted in delay of treatment of a right femoral neck fracture and ongoing, continuing pain.

Failure of the nursing staff to consistently oversee the care and safety of patients placed all patients at risk of injury, harm, or death.

Findings Include:

Review of undated RN Job Description showed, "Assumes leadership responsibility for day-to-day coordination of patient care activities for the unit while maintaining standards of professional nursing practice in accord with TJC (The Joint Commission), federal, and state regulations ...Coordinates the performance of nursing care to patients within the scope and practice and in compliance with policies, procedures, and standards. Communicates with the medical staff on identified patient issues. Performs patient care assessments timely and accurately. Addresses patient care needs in a timely manner. Documents finding into the medical record accurately and timely ...Ensures all admission and daily documentation is completed thoroughly and signed and dated according to protocol". Under section titled, "Duties and Responsibilities," showed, "5. Communicates with medical staff on patient care issues. Receives and implements physician orders accurately and timely. Transcribes orders accurately."

Review of the undated hospital policy titled, "Nursing Documentation: Nsg #1001", showed, ... "Documentation of nursing care is to be pertinent, concise, and reflect the status of the patient. ...Narrative entries are to be made for any significant change in the patient's status or treatment. ...Narrative statements are also used to document calls placed to physician and therapists as well as others involved in the patient's care ...Al [sic] documentation will be performed in a timely manner."

Review of the hospital policy titled, "Medical Record Content Policy", revised 5/19, showed, ... " ... the time and date of each entry (orders, reports, notes, etc.) must be accurately documented."


Patient 1

Review of Patient 1's medical record showed she was an [AGE] year-old female with a voluntary admission to this psychiatric hospital on [DATE] with diagnoses of [DIAGNOSES REDACTED] (under active thyroid), and congestive heart failure (CHF) (inability of the heart to pump blood properly).

Review of the admission nursing assessment completed on 03/11/20 by Staff P, Registered Nurse (RN) showed she was admitted from an assisted living facility after she became aggressive to staff and other patients. At admission documentation showed she was ambulatory requiring no assistance, had no alterations in mobility or comfort. Her fall risk score was 15 showing she was at moderate risk of falls due to age, medications, confusion, and poor balance requiring the initiation of fall precautions. She was placed on close observation for violence, falls, and elopement requiring documentation every 15 minutes of her location and activity.

Review of orders signed by Staff Q, Psychiatrist, on 03/12/20 for Patient 1 included vital signs twice daily (BID), observation every 15 minutes, reconciliation of home medications, and as needed (prn) Tylenol 325 mg(milligrams), two tablets by mouth every eight hours for temperature over 100 degrees or for pain, EKG, and lab including TSH (thyroid), vitamin B12 level, Vitamin D level, and lipid panel. Additional orders by Staff Q on 03/12/20 showed the discontinuation of Abilify (antipsychotic), Buspar (antidepressant), and Zoloft (antidepressant) and the addition of Risperdal (antipsychotic) 0.5 mg PO at night and Remeron (antidepressant)7.5 mg PO at night.


Review of the document titled, "Master Treatment Plan of Care: Fall Precautions", for Patient 1 included treatment team goals including, "Will remain free from falls ...Assist with toilet and ask for assistance and pushing call light." Nursing Interventions included the following, "Patient 1 will be assessed each shift for sedation, Will provide education if needed, and Assist with toileting every two hours."


Documentation on 03/15/20 at 7:30 AM, the nursing daily note by Staff F, RN showed Patient 1 was exit seeking, wandering the halls, upset with redirection, and confusion.

Review of the "At Risk for Falls (ARF) Score Sheet", revised on 02/26/17, showed, ... "Patient Scoring 8 -24 Moderate Risk (Initiate Fall Precautions). FALL PRECAUTIONS for Patients at Moderate/High Risk: ... Patient Is Not Left Unattended During Activities That Place Him/Her At Increased Risk of Falling."

During a telephone interview with Staff G, agency RN, on 03/19/20 at 9:06 AM she stated that on 03/15/20 around 6:15 PM, she was putting the fire alarm cap back on after Patient 1 set it off. Patient 1 was walking without assistance in the hallway and then after she set the fire alarm off, she was "running" down the hall. Nursing staff failed to accompany Patient 1 while she was acting out (setting off the fire alarm) and "running" down the hallway. Per policy, the patient should not have been left unattended during these activities that put her at increased risk of falling. She further stated that following the fall, Patient 1 refused to allow vital signs and she "acted like her leg hurt, but there was not anything physical that we could see". When we got her up we walked her about 4 feet to her bed. "We performed an assessment including her leg, however without removing her pants all the way but could see her hip."


Review of the "ARF Score Sheet" showed Staff I reassessed Patient1's fall risk on 03/15/20 at an undocumented time with a score of 15 and Staff H, DON reassessed Patient 1's fall risk again on 03/15/20 at an undocumented time with a score of 20. Nursing Staff failed to time the entries into the medical record.


Review of the "Multi-Disciplinary Note," dated 03/15/20 at 6:15 PM by Staff F RN, showed, Patient 1 "Put self on floor and c/o (complained of) right lower extremity (RLE) pain. Order for two view X-ray obtained." The medical record lacked documentation that Staff F, RN transcribed a physician's order for the X-rays of Patient 1 when she notified Staff K, Doctor of Osteopathy (DO) of the patient's fall on 03/15/20 at 6:30 PM. The medical record failed to contain any documentation of the information that Staff F, RN shared with Staff K, DO about Patient 1's condition after her fall.


During an interview on 03/18/20 at 4:00 PM, Staff F, RN said she was at the desk on 03/15/20 when Patient 1 fell , but she did not see her fall. She stated, "I heard Patient 1 say, "I'm falling" and by the time I stood up she was on the floor on her left side." Patient 1 immediately complained of right leg pain. She then stated the three-staff helped her up and got her into bed. Patient 1 did not bear weight on the right. Staff F, RN stated vital signs were stable and the patient was assessed. Patient 1 was unable to describe the pain. The assessment showed she had external rotation, no shortening, and was able to pull her knee up a little bit. She was combative and aggressive. Staff F stated that she notified Staff K, DO of the fall and he ordered an X-ray. Staff F, RN said that there was no discussion with Staff K, DO regarding sending Patient 1 to the hospital nor was anything ordered for pain. Patient 1 had a standing prn order for Tylenol. She stated she called the mobile X-ray company after she received the order from Staff K. She then stated, "It is my understanding that X-ray did not come out until the next day." Patient 1 did complain of pain, but only when she was moved. Staff F further stated during her post fall assessment she was able to localize the pain to the right leg and the "leg was definitely rotated out". She then stated she told Staff K, DO that the leg had slight rotation out, some shortening, and she was in pain.


Review of the hospital policy titled, "Patient Fall Risk", revised 12/16 showed, ... "The ...Psychiatrist will be contacted by the charge nurse to determine the course of treatment after the patient has fallen".

Review of the hospital policy titled, "Incident Report", revised 12/16, showed, ... "Incident reports are a confidential document for facility use only."

The medical record lacked any evidence that Staff F notified the physician of Patient 1's inability to bear weight on her right leg and that the patient had 10/10 sharp, constant pain. Her documentation of 10/10 pain on the "Post Fall Assessment" contradicts her interview statement that Patient 1 was unable to describe the pain. Per interview, the patient's right leg had slight rotation out and some shortening (displaced fractures of the femoral neck will classically cause external rotation and shortening of the leg when the patient is laying supine). The medical record lacked any evidence that Patient 1 had external rotation and shortening. The "Incident/Accident Report" contained one set of vital signs, however, this document is not part of the patient's medical record. The medical record lacked documentation that Staff F or any other nursing staff contacted the Psychiatrist after Patient 1's fall per policy. The medical record failed to contain any documentation Staff F or any other nursing staff notified the mobile X-ray company after nursing staff received the order for the portable X-ray on 03/15/20 at 6:30 PM.

During an interview on 03/23/20 at 10:46 AM, Staff H, DON stated that she was at the facility the day Patient 1 fell . She stated that she did not do an assessment but did see the presence of leg swelling. She instructed the nurse (Staff F) to contact the physician and have Patient 1 sent to the emergency department (ED). The nurse called Staff K, DO who ordered a portable X-ray instead. Staff H stated that if a nurse does not agree with a physician's order they are to call the DON or the administrator on call (AOC).


Review of the hospital policy titled, "Post Fall Process", revised on 3/17, showed, "In the event that a patient experiences a fall, the following process will be followed: medical care provided if injury is sustained and under the orders of the physician; the Post Fall Assessment Form will be completed after a patient has fallen; and notification to the DON."

Review of the document titled, "Post Fall Assessment", completed by Staff F, RN on 03/15/20 at 6:45 PM showed vital signs and neurological assessment should be completed every 15 minutes times two, every 30 minutes times two, every hour times two, and every four hours times two following a fall. Nursing staff (Staff F, Staff I, or any other nurse) did not complete any vital signs on this form and completed only two sets of untimed vital signs on the "Graphics/Vital Signs Flowsheet" on 03/15/20. Nursing Staff F documented only one neurological assessment on the form on 03/15/20. Staff F, Staff I, or any other nurse failed to document or assess Patient 1's neurological status any further on the "Post Fall Assessment" for the 7.5 hours following Patient 1's fall. Staff F, RN further documented on the "Post Fall Assessment" form that Patient 1 had decreased range of motion of her RLE, a pain level rated 10 out of 10 (0 no pain, 10 worse pain), described as sharp and constant. The medical record lacked any evidence that Staff F or any other nursing staff administered any pain medication to Patient 1 at the time of the fall for her c/o 10/10, sharp, constant pain or obtained a physician's order for any stronger pain medication than the Tylenol Patient 1 already had ordered at admission. The medical record lacked any evidence that Staff F notified the physician of the external rotation of Patient 1's RLE which is a sign of a femur fracture. Staff F and Staff I failed to fill out the "Post Fall Assessment" form completely per policy.

Nursing staff failed to fill out the "RN Post Fall Screen for Fall Precautions" completely and accurately. Nursing staff failed to mark "Yes" or "No" to the question about the use of assisted [sic] devices. Nursing staff failed to indicate that Patient 1 used a walker as documented on nursing assessment. Nursing staff failed to mark "Yes" or "No" to the question about over sedation. Nursing staff failed to mark "Yes" or "No" to the question about Blood pressure (BP) (orthostatic hypotension) although "Lying" is checked and a BP of 112/58 was documented on the line labeled, Irregular pulse rate. Nursing staff failed to mark "Yes" or "No" to the question about Irregular pulse rate and there is no other number documented on the form to indicate Patient 1's pulse. Nursing staff failed to circle either "Mild", "Moderate", or "High" on the question about fall "Level Identified". Nursing failed to mark "Yes" or "No" to the question about whether "Interventions changed on treatment plan".

Review of the document titled, "Fall Analysis Form," showed, Staff G, RN indicated the fall was not medication related, but was related to the patient's mental health. She further document X-rays were ordered, and the activities/processes occurring at the time of the fall could cause the fall. Staff H, DON did not sign the document even though she indicated that she was present at the facility the day Patient 1 fell and Staff F, Staff I or any other nursing staff failed to document notification of the Patient 1's fall to the DON.

Nursing Staff failed to fill out the "Fall Analysis Form" dated 03/15/20 completely and correctly. Nursing Staff documented Patient 1 was identified as a fall risk on admission but marked "NA" (not applicable) to the question, "Was the Fall Risk Protocol implemented and documented after admit/prior to fall?". Nursing staff marked "NA" to the question "Were any environmental factors involved in this event?" Even though, the next line asks the recorder to "Please identify the environmental factor" and the nursing staff documented, "Turning on fire alarm." Nursing staff marked both "Yes" and "No" to the question, "Was staffing adequate according to grid?". Nursing staff marked "Yes" to the question, "Activities/processes occurring at this time that could be factors in cause of this event?" However, nursing staff failed to identify what activity/process was a factor in Patient 1's fall.


Review of the hospital policy titled, "Incident Report", revised 12/16, showed, ... "All sections of the Incident report must be completed."

Nursing staff failed to fill out the "Incident/Accident Report" dated 03/15/20 completely. Nursing staff failed to complete the section of the report asking for "Previous Fall Score and New Fall Score".


Staff I, RN documented on a "Nursing Daily Note" on 03/15/20 at 10:00 PM that Patient 1 had a complaint of (c/o) pain 10/10 of her RLE when the nurse administered her night time medications and so she gave Patient 1 650 mg (milligrams) of Tylenol (APAP - analgesic that treats mild aches and pains) at 9:05 PM (about 2 hours and 50 minutes after the fall). Staff I, RN indicated the APAP was ineffective and she called the doctor and received an order for the narcotic pain medication, Norco. The record showed that nursing staff administered Norco at 10:35 PM and that Patient 1 fell asleep.

During a telephone interview with Staff I, Agency RN on 03/19/20 at 10:17 AM, she stated that the night Patient 1 fell during the prior shift, Staff F had obtained an order for an X-ray from Staff K, DO but it was not a STAT order. After report, she stated Patient 1 was in bed and not complaining of pain at that time. Staff I, RN stated later into the shift Patient 1 started complaining of pain and I gave her Tylenol which seemed to relieve the pain until 10:00 to 10:30 PM when the pain became worse. She stated she contacted Staff K, DO who gave an order for Norco which I gave Patient 1 every four hours during the night. At some point, she stated the mobile X-ray company called stating they would not be available to do the X-rays until midnight and Staff I, RN told them to wait until morning because the patient was sleeping. She stated she gave that information to Staff K, DO when she called for the pain medication order. He told her if the pain medication did not keep her comfortable to call him again and he would send her to the ED. Because the pain was relieved she did not call the doctor back. She stated staff repositioned her several times during the shift and she remained comfortable. During the night chart audit, she stated that she did not see the order for Patient 1's mobile X-ray.

Additionally, the medical record showed that Staff I, RN administered Norco on 3/16/20 at 2:30 AM for c/o 10/10 pain in the RLE and on 3/16/20 at 6:30 AM for c/o 10/10 pain in the RLE.

The medical record lacked evidence that Staff I obtained an order from Staff K, DO to hold the X-ray until the morning. After she conducted the night chart audit and found the order for Patient 1's X-rays missing, Staff I failed to obtain an order for the X-ray from Staff K, DO that had not been transcribed by Staff F, RN.

The medical record showed that Staff E, Agency RN administered Norco on 3/16/20 at 11:15 AM for c/o 10/10 pain in the RLE. The medical record lacked evidence that Staff E assessed or documented Patient 1's response to pain medication administered on 03/16/20 at 11:15 AM.

The medical record showed an order for an X-ray of Patient 1's right hip and right upper leg on 03/16/20 at 1:30 PM (around 19 hours after the fall) and Staff E failed to write the order as STAT. The mobile X-ray company performed Patient 1's X-rays on 03/16/20 at 1:43 PM (around 19.5 hours after the fall).

Documentation from the mobile X-ray company showed they arrived at the hospital on [DATE] at 1:43 PM and performed an X-ray of both hips and the right femur. Their clinical note showed a right femoral neck fracture and the results were called to nursing staff at the hospital on [DATE] at 3:30 PM.

The medical record failed to indicate whether the order received by the nursing staff on 03/16/20 at 1:30 PM for a straight cath (catheter) (used to take a sample of urine from a patient, meant for temporary use and is removed and disposed of or sterilized immediately afterwards), urinalysis with culture and sensitivity, and X-ray to right hip and right upper leg was a telephone or verbal order, the name of the Doctor who gave the order, and a read back verification of the order. The order did contain Staff K, DO's undated, untimed signature.

The medical record showed that Patient 1 transferred to a local acute care hospital's (hospital B's) emergency department (ED) on 03/16/20 at 4:30 PM (around 22 hours after the fall) for treatment of a right femoral neck fracture.

Medical record from the acute care hospital B showed that Patient 1 had surgical repair of the right hip on 03/17/20.

During an interview on 03/18/20 at 6:30 PM, Staff E, Agency RN, stated she has worked at this facility for two weeks. She stated she worked the nursing desk on 03/16/20 starting at 7:00 AM. She performed an assessment of Patient 1 and saw the right leg rotated out and 3 inches shorter than the left with minimal bruising. She was told in report that Patient 1 had fallen the evening before. She stated she called the mobile X-ray company to ask about an expected time of arrival to perform Patient 1's X-rays and was told it "would be pretty soon." She further stated that she called Staff K, DO and he did not answer. She stated that she didn't remember what time she made the first call. She called Staff K, DO for a second time on 03/16/20 at 10:34 AM and told him the X-ray had not been performed, gave him the results of her assessment, and he made the decision to wait to transfer Patient 1 to the ED until after the X-ray results were available. Staff E, RN stated that she was unable to find the original X-ray order, so she wrote the order and called the mobile X-ray company again at 12:20 PM. Mobile X-ray arrived shortly after the last phone call and the results of fractured femur were reported. Staff K, DO came into the facility at some time around the time the mobile X-ray company came. He signed the order but did not assess the patient. Staff E, RN stated she reported her assessment to Staff H, DON including her belief Patient 1 had a RLE displacement or fracture and Staff K, DO refused to send her to the hospital prior to the X-ray. "I do not know if Staff H, DON assessed Patient 1, but I do know she was aware I had called X-ray a couple of times."

The medical record lacked documentation that Staff E notified Staff K, DO of the X-ray results on 03/16/20. The medical record lacked evidence of documentation that Staff E transcribed Patient 1's transfer order to the acute care hospital on [DATE]. The medical record lacked evidence that Staff E documented vital signs on the "Graphics/Vital Signs Flowsheet" on 03/16/20. The medical record lacked evidence of nursing assessment or documentation of fifteen-minute checks on the "Close Observation Sheet" on 03/16/20.

The medical record lacked evidence of the phone calls Staff E made to the mobile X-ray company or the requests or inquiries made on 03/16/20. The medical record lacked evidence that Staff E, RN documented the conversations she had with the DON expressing concerns about Patient 1's care (information obtained by interview): She said that she assessed Patient 1 and her leg was rolled out and was 3" shorter. She had only minimal bruising. She stated that she called the Physician and he did not answer (didn't recall the time of the first call) and so she called back at 10:34 AM and told him X-ray had not come out and gave him the results of her assessment, asking if Patient 1 could transfer to the hospital. She stated that he said to wait to transfer the patient until after the X-ray. Nursing staff called the mobile X-ray company around 12:20 PM and changed the priority of the X-ray to STAT. The nursing staff said that she had a couple of conversations with the Director of Nursing (DON) regarding concerns about Patient 1's injury and waiting for the portable X-ray instead of transferring the patient to the local acute care hospital. The medical record lacked documentation of these conversations and there was no documentation in the medical record indicating that the DON reviewed the situation or took any actions on behalf of Patient 1.

During a telephone interview on 03/19/20 at 8:13 AM, Staff J, Supervisor of the contracted mobile X-ray company, stated Staff X, Receptionist received orders from a staff RN at the hospital for a right hip and right femur X-ray post fall per Staff K, DO on 03/15/20 at 6:43 PM. The order was not flagged as STAT (immediately). On 03/15/20 at 10:23 PM, X-ray technician Staff Y documented the X-ray would be rescheduled for 03/16/20 per a hospital nurse. Further documentation by dispatcher Staff Z showed that a hospital nurse called on 03/16/20 and asked if the X-ray was going to be done this morning. At that time, the order was changed to STAT. Staff Z sent a message to an X-ray technician at 12:33 PM requesting an estimated time of arrival. The X-ray was taken at 2:02 PM. The results showing a right femoral neck fracture were faxed on 03/16/20 at 2:25 PM to the hospital and we also notified the hospital nurse by telephone.


During telephone interview on 03/19/2020 at 7:38 AM, Staff K, DO, stated he did not remember what day or time he was called about Patient 1 following her fall, but remembered getting a call from a nurse and giving an order for a portable X-ray. He stated the decision to not send her to the ED for an evaluation was based on the nursing assessment given to him over the phone. The RN giving the report did not suspect a fracture. He stated he received a second call at an unknown date or time by a nurse with a report that the X-ray had been completed and he thought she was transported to the ED prior to being seen by him or one of his mid-levels. Staff K, DO had no recall of being at the hospital on [DATE] or of giving orders for additional pain medication during the night. Staff K, DO stated he depends on the nursing assessment to help make his medical decisions.

During a second interview on 03/23/20 at 1:22 PM, Staff K stated he told the nurse to send Patient 1 to the ED and the nurse offered a mobile X-ray first and he agreed. He clarified the X-ray was not ordered STAT, but just to be done the same day, but sometime on 03/16/20 staff called and told him the X-ray was not done. Staff K reviewed the orders for Patient 1 and verified there was not a physician's order written by nursing as a telephone order for the X-ray he requested on 03/15/20. He was notified by a nurse "at some time" that her (Patient 1's) leg was rotated and shortened but did not recall when he received the information.

During an interview on 03/18/20 at 4:48 PM, Staff H, DON stated that she spoke with Staff K, DO regarding Patient 1's X-ray orders and the delay in obtaining the X-rays. He told her the initial X-ray was ordered STAT (immediately). He further told her X-ray called at midnight and asked to perform the X-ray in the AM and staff called him to verify he would authorize the delay.

During another interview on 03/23/20 at 10:46 AM, Staff H, DON stated that she was unaware Staff K, DO was in the building the next day, Monday 03/16/20 and stated since he was in the building her expectation would be that would have assessed Patient 1.

During an interview on 03/23/20 at 11:05 AM, Staff L, CEO stated that an administrator is always on call 24/7 and all clinical questions are deferred to Staff H, DON. If she is unavailable then the physician, or the charge nurse would make the decision. Staff L stated if the nurse disagrees with the physician's order the nurse can speak with the hospital corporate nurse. He did state that he does know the "nurse's scope allows them to push back anytime they want." The administrator on-call list with phone numbers are posted in the nurse's station. Staff L further stated that he was unaware Staff K, DO refused to send Patient 1 to the hospital without first obtaining the X-ray and was not aware of the delay in obtaining the X-ray. He was also unaware Staff K, DO was in the hospital the day following the fall and did not assess Patient 1. He clarified that in this situation the nurse should have notified administration that the physician did not see the patient and did not send her to the ED.



Patient 3

Review of Patient 3's medical record showed a [AGE]-year-old female medical with an involuntary admission to this psychiatric hospital on [DATE] with diagnosis of [DIAGNOSES REDACTED]

Review of the admission nursing assessment completed on 02/22/20 by Staff R, RN showed she was admitted from home due to social isolation, legal problems, non-compliance with treatment and a history of psychotic disorders. At admission, documentation showed she was ambulatory requiring no assistance, had no limitations in mobility or comfort, and was independent in self-care. Her fall risk score was two showing she was low risk for falls, requiring nursing staff to initiate no fall precautions.

Review of the untimed "Multi-Disciplinary Note," dated 03/12/20, by Staff F, RN documented Patient 3 was in the shower and refused to follow directions given by an unidentified mental health technician (MHT) by refusing to dry her feet. She pushed past the MHT onto the tile and fell . Documentation showed the patient had a lump and bruising noted on the left elbow.

Review of Patient 3's "ARF Score Sheet" showed her fall risk score was reassessed on 03/01/20 and 03/15/20 at undocumented times with a continued score of two on each assessment. Nursing staff failed to time their entries on the ARF Score Sheet; failed to reassess her fall risk score on 03/08/20 weekly per protocol and failed to reassess her fall risk score after her fall on 03/12/20 per protocol. The fall risk score documented on 03/15/20 failed to include additional points for the fall Patient 3 had on 03/12/20. Nursing staff is supposed to identify a patient as a fall risk after a fall per protocol and the medical record lacked any evidence that nursing staff implemented any new interventions to prevent additional falls or add anything to her care plan per protocol.

Review of Patient 3's "Post Fall Assessment Form," showed she refused vital signs and Staff F conducted one neurological assessment at the time of the fall. Staff F or any other nursing staff failed to take vital signs and neurological assessments every 15 minutes times two, every 30 minutes times two, every hour times two, and every four hours times two following the fall per protocol. Nursing Staff F, RN or any other nursing staff failed to document any vital signs on the "Graphics/Vital Signs Flowsheet" on the day of the fall indicating she refused. Failure of the nursing staff to complete vital signs and neurological checks per protocol placed Patient 3 at risk for nursing staff failing to recognize an early sign of deterioration in her condition. Additionally, the nursing staff failed to document notification of Patient 3's fall to the DON.

Further review of Patient 3's medical record failed to contain any documentation of reassessment of the "lump and bruising" of her left elbow.

Additional review of Patient 3's medical record showed on the "Graphics/Vital Signs Flowsheet" that the patient refused vital signs on the following days: 02/25/20 - 3/01/20, 03/04/20 - 03/14/20, and 03/17/20. The medical record lacked documentation that any nursing staff notified the physician that the patient was refusing vital signs. The patient had a history of hypertension and was taking a medication to treat the high blood pressure named Norvasc 5 mg daily at 9:00 AM. Failure of the nursing staff to report the patient's continued refusal to have vital signs assessed placed her at higher risk for an adverse reaction to her medication or for ineffective management of her high blood pressure.

Failure of the nursing staff to conduct vital signs and neurological assessments per the post fall protocol; failure of the nursing staff to document reassessments of an area injured during a fall; failure of the nursing staff to notify the DON of a fall; failure of the nursing staff to document notification to the physician of the patient's continual refusal to have vital signs taken placed Patient 3 at risk for deterioration of her condition, worsening of her injury, and unrecognized high or low blood pressure.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on observation, interview, document review, and policy and procedure review the hospital failed to ensure the COVID-19 infection control plan, education, oversite, and implementation was provided to patients, staff, and others ensuring the safety of all and attempt to control the introduction and spread of COVID-19.

The cumulative effect of the hospital's failure to ensure education, oversite, and implementation of the COVID-19 infection control plan, has the potential to place all patients and staff at risk of illness leading to death.

Findings Include:

Review of the personnel records for Staff H, DON failed to provide documented evidence of infection control training or that she was qualified through education, training, experience, or certification in infection prevention and control. (Refer to A-0748).

The Governing Body failed to ensure the Infection Preventionist maintained the implementation of the system for tracking infection surveillance, prevention and control and demonstrated success and sustainability of the COVID-19 infection control program. (Refer to Tag A-0770).

Review of the hospital's COVID-19 Readiness Binder followed by observation and interview, the hospital did not follow the "Coronavirus Protocols Checklist" by not providing evidence of training regarding visitation, infection control, screening, and they did not implement social distancing, limit communal dining, serve meals to the patients in their rooms or cancel group activities (Refer to Tag A-0772).

Review of the hospital's COVID-19 Readiness Binder followed by interview, the hospital failed to provide evidence of competency-based infection control training for all facility staff, providers, and contracted staff and failed to provide infection control training to patient. (Refer to Tag A-775).
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on document review, policy review, and staff interview, the Governing Body failed to appoint an individual who is a qualified Infection Preventionist responsible for developing and overseeing the COVID-19 infection control program. Failure of the Governing Body to appoint a qualified individual in the role of Infection Preventionist places all patients, employees, and visitors at risk of illness or death.

Findings Include:

Document review of the undated hospital policy titled "IC-1016: Infection Prevention and Control Plan" showed administration was responsible for appointing an infection preventionist who is responsible for prioritizing risks, setting goals and measurable objectives, establishing activities based on the goals and objectives using evidence-based national guidelines or expert consensus when developing the prevention activities.

Review of Staff H's, Director of Nursing, (DON) personnel file lacked evidence of documented education related to the national standards of infection prevention and control or evidence she had completed training for the role of Infection Preventionist. Staff H's personnel file also lacked documented evidence of her appointment by the governing body as the hospital Infection Preventionist.

During an interview on 03/24/20 at 3:18 PM, Staff H, DON stated that she was appointed the Infection Preventionist in 06/2019 and that her training was with corporate and a meeting in another state.

Staff H was unable to provide documented evidence of infection control training with corporate and a meeting in another state or that she was qualified through education, training, experience, or certification in infection prevention and control.
VIOLATION: LEADERSHIP RESPONSIBILITIES Tag No: A0770
Based on interview, document review and policy review the Governing Body failed to ensure the Infection Preventionist maintained the implementation of the system for tracking infection surveillance, prevention and control and demonstrated success and sustainability of the COVID-19 infection control program. Failure of the Governing Body to ensure the Infection Preventionist maintained the implementation of the system for tracking infection surveillance, prevention and control and demonstrated success and sustainability of the COVID-19 infection control program has the potential to place patients at risk for acquiring COVID-19 during their hospitalization resulting in illness or death.

Findings Include:

Review of the Hospital's undated document titled, "Governing Body By-Laws," showed ...the governing body shall have charge of maintenance and operation of the Hospital and shall continually study and investigate the health needs of the community served ...the governing body retains ultimate authority for the quality of patient care rendered in the hospital.

The Governing Body By-Laws lacked documented evidence of their responsibility to appoint an Infection Preventionist.

Document review of the hospital's undated COVID-19 readiness binder containing a policy titled "Infection Prevention and Control Plan" that showed, implementation of the facilities infection prevention and control plan requires ensuring the infection policies are followed by all staff, patients and visitors, and staff competency includes managing equipment and devices accomplished by education of patients and staff about infection prevention and control guidelines, review of policy and procedure with evaluation, and communication responsibilities about preventing and controlling infection including hand hygiene and respiratory hygiene practices to all staff, medical staff and patients.

During an interview on 03/24/20 at 5:30 PM Staff H, Director of Nursing (DON) stated that she is the appointed Infection Preventionist at the hospital and COVID-19 specific infection control policies have not been developed. Staff H stated that she has not provided any additional oversite for compliance.

Review of Staff H's personnel file lacked evidence of her appointment by the governing body as the hospital Infection Preventionist and lacked documented evidence of education related to the national standards of infection prevention and control or evidence she had completed training for the role of Infection Preventionist.
VIOLATION: IC PROFESSIONAL RESPONSIBILITIES POLICIES Tag No: A0772
Based on observation, staff interviews, document review, and policy review the hospital failed to ensure the Infection Preventionist developed and implemented hospital-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines for COVID-19. Failure to develop infection control surveillance, prevention and control policies and procedures for COVID-19 places all patients, staff, and other individuals entering the hospital at risk of illness and death.

Findings Include:

Review of the Hospital's COVID-19 Readiness Binder's policy titled "Infection Control-Emergency Management Plan/Influx of Infectious Disease", revised date 10/24/19, showed the purpose of the policy was to establish an infection control emergency management plan to respond to the influx or risk of influx of infectious patients ... keeping abreast of current information about the emergence of epidemics. The policy showed the infection control officer is to stay up to date with current information referencing the Centers for Disease Control and Prevention (CDC) and provide updates to staff.

Review of the hospital's COVID-19 Readiness Binder's undated policy titled "Infection Prevention and Control Plan" showed implementation of the facilities infection prevention and control plan requires ensuring the infection policies are followed by all staff, patients and visitors, and staff competency includes managing equipment and devices accomplished by education of patients and staff about infection prevention and control guidelines, review of policy and procedure with evaluation, and communication responsibilities about preventing and controlling infection including hand hygiene and respiratory hygiene practices to all staff, medical staff and patients.

Review of the hospital COVID-19 Readiness Binder included an undated document titled, "Coronavirus Protocols Checklist" The check list showed: In-service staff on visitation, infection control, screening, social distancing ... Limit communal dining. All patients will be served meals in their rooms. No group activities ... The checklist was provided to the hospital by Staff BB, President/Chairman.

Through observation, the hospital did not follow the "Coronavirus Protocols Checklist" for the following items: They did not provide evidence of staff or patient training regarding visitation, infection control, screening, and did not implement social distancing, by failing to limit communal dining, serve meals to the patients in their rooms or cancel group activities.

During observation in the day room on 03/23/20 at 12:00 PM, patients were gathered around a table for lunch with no social distancing observed, patient census on 03/23/20 was 10.

During observation in the day room on 03/24/20 at 3:15 PM, Staff A, mental health technician (MHT) was performing observation of patients and providing snacks, he had a plastic container with individually wrapped fruit cups, crackers, granola bars and Styrofoam cups holding plastic unwrapped spoons. Patient 7 was observed reaching into the container, removing a package of crackers. Hand hygiene was not performed prior to reaching into the container. Staff A, MHT did not instruct the patient to wash his hands or instruct him not to reach into the container.

During the interview on 03/24/20 at 3:20 PM Staff A, MHT stated he was aware staff are to perform hand hygiene every time they have contact with a patient. He stated that he "usually asks patients to wash their hands prior to reaching into the container to get a snack, but did not at this time." Staff A, MHT, was observed constantly rubbing his hands all over his face during the interview. When he finished rubbing his face, he did not perform hand hygiene. He was questioned regarding the touching of his face and lack of hand hygiene and he stated, "now? I am supposed to be doing observations."

Following the interview with Staff A, Staff H, DON instructed Staff A, MHT, that patients are not allowed to reach into the container for a snack, but must request the snack of their choice and staff are to hand it to them. Immediately following this interaction, an unidentified patient was observed reaching into the container for a snack and Staff A instructed them to wash their hands. The patient immediately left the area without washing their hands.

During observation in the day room on 03/24/20 at 4:00 PM, seven patients were gathered around a table with one RN for the afternoon education session. The patients and RN did not practice social distancing with a minimum of six feet between each person. Staff H, DON and two unidentified patients were observed refilling cups they brought into the room with ice and water at the dispenser on the counter next to the sink. No hand hygiene was observed, and no gloves were used for refilling the cups. There was no evidence that clean cups were available for use.

During the survey, hospital staff were not observed wearing or utilizing any form of Personal Protective Equipment (PPE), gloves in particular, when passing medication, serving meals or cleaning tables after meals

During an interview on 03/24/20 at 5:30 PM Staff H, DON stated she is the appointed Infection Preventionist at the hospital and COVID-19 specific infection control policies have not been developed. She stated the hospital has pushed information out to the staff regarding COVID-19 from the beginning about the need of hand hygiene for both patients and staff. She stated because hand gel cannot be kept within patient reach for safety concerns it is located behind the nursing desk and on the medication cart. She further stated that she has not provided any additional education to staff other than the information provided by the corporate office sent to staff through bamboo (facility text messaging program) and that she has not provided any additional oversite of compliance.
VIOLATION: IC PROFESSIONAL TRAINING Tag No: A0775
Based on staff interviews, document review, and policy review the Infection Preventionist failed to provide COVID-19 competency-based infection control training for all facility staff, providers, and contracted staff. Failure to provide competency-based education and training of all staff following national standards of infection control practices places patients, staff, and visitors entering the hospital at risk for illness and death.

Findings Include:

Review of the undated hospital policy titled "IC-1016: Infection Prevention and Control Plan" showed administration was responsible for appointing an Infection Preventionist who is responsible for prioritizing risks, setting goals and measurable objectives, establishing activities based on the goals and objectives using evidence-based national guidelines or expert consensus when developing the prevention activities. The plan further showed the Infection Preventionist is responsible to ensure staff, patients, and visitors follow infection control policies and procedures and to ensure staff competency.

Review of the hospital's COVID-19 binder, a policy titled "Infection Control-Emergency Management Plan/Influx of Infectious Disease", revised date 10/24/19, showed the infection control officer is to stay up to date with current information referencing the Centers for Disease Control and Prevention (CDC) and provide updates to staff.

Review of the hospital's COVID-19 Readiness Binder, an undated policy titled "Infection Prevention and Control Plan" showed implementation of the facilities infection prevention and control plan requires ensuring the infection control policies are followed by all staff, patients and visitors. Staff competency includes managing equipment and devices accomplished by education of patients and staff about infection prevention and control guidelines, review of policy and procedure with evaluation, and communication responsibilities about preventing and controlling infections, including hand hygiene and respiratory hygiene practices to all staff, medical staff and patients.

During the interview on 03/24/20 at 3:20 PM Staff A, MHT stated he was aware staff are to perform hand hygiene every time they have contact with a patient. He stated that they have a yellow spray bottle to clean the tables after meals, but he didn't know what was in the bottle or the dwell time (the time the solution is left wet on a surface that will kill germs).

During interview on 03/24/10 at 2:40 PM Staff O, MHT, stated that there had been no formal training regarding the COVID-19 virus and special precautions staff are to take, however she stated staff have received multiple pieces of information through bamboo (facility text messaging program). She stated she was aware that hand washing was important and hand gel was available at the nursing station. She further stated that she keeps gloves in her scrub pocket and additional personal protective equipment are located in the soiled linen closet and laundry room.

During an interview on 03/24/20 at 5:30 PM Staff H, DON stated she is the appointed Infection Preventionist at the hospital and COVID-19 specific infection control policies have not been developed. She stated the hospital has pushed information out to the staff regarding COVID-19 from the beginning about the need of hand hygiene for both patients and staff. She further stated that she has not provided any additional education to staff other than the information provided by the corporate office sent to staff through bamboo and that she has not provided any additional oversite of compliance.