The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on interview, record review and a review of hospital documentation, the hospital failed to ensure that it reported to CMS (Ceters for Medicare & Medicaid Services) each death that occurs within 24 hours after the patient has been removed from restraint in the form of full side rails with an exit seeing patient for 1 of 18 sampled patients (#1).


A physician's note of 3/21/21 at 10:08 AM read, "General appearance: chronically ill appearing, confused, alert, awake....Status post right TMA (Transmetatarsal amputation) and left BKA (below knee amputation) - surgical dressing clean dry and intact. Neuro/CNS (Central Nervous System): disoriented, alert. Psychiatry: abnl judgment/insight." A physician's note of 3/24/21 at 9:39 AM read, "Patient over all stable clinically. Vitals stable. .... Remains confuse[d]."

The hospital produced documentation from their Avasys Tele Sitter program covering 3/24/21. This system allows a Tele Sitter (or Patient Safety Attendant) to view a patient remotely through a camera and activate alerts if a patient exhibits behavior that could result in self-harm. It had been used with the patient since 3/17/21 at 2:04 AM. The entries, authored by Patient Safety Attendant (PSA) A, read:
1:04 PM: Confused/Disoriented/Restless/Fidgety.
1:09 PM: Getting out of bed.Tech interventions: activate alarm. Call Nurse/Tech.
1:40 PM: Confused/Disoriented. Reaching out of bed. Impulsive. Tech Intervention: Activate alarm. Call nurse/tech. Comment: Patient is actively trying to get out of bed and is hurting his surgery on his leg I called the supervisor... and said that patient needs sitter."
2:00 PM: Confused/disoriented. Reaching out of bed. Impulsive. Tech interventions: Activate alarm. Call nurse/tech.
2:58 PM: Confused/disoriented. Reaching out of bed. Pulling lines/tubes. Tech interventions: Activate alarm. Call nurse/tech.
3:04 PM: Patient got up out of bed and fell on the floor. I had the alarm on and was calling the nurses station (PTA C) went in to the room to check on the patient. Patient fell possibly hit his head in the fall. Time approximately 3:04 PM.

On 6/02/21 at 3:06 PM, the Director of Nursing stated that the Relief House Supervisor began looking into obtaining a live sitter at approximately 1:45 PM. She stated that after the patient's fall, they learned that the side rails had been raised, but they could not determine at what time they were raised or who raised them. They suspected that it was at some point after 2:30 PM. They determined that the side rails had been up at the time of the fall during the post-event review.

A computed tomography (CT scan) of the head/brain without contrast was ordered for the patient on 3/24/21 at 3:30 PM. The CT Head/Brain w/o (without) Cont (contrast) of 3/24/21 at 5:41 PM read, "Impression: small to moderate acute left subdural hematoma with 3 MM (millimeter) of midline shift to the right."

A nurse's note of 3/24/21 at 6:39 PM read, "Pt being transferred to higher level of care after falling out of bed and hitting head. An Advanced Practice Registered Nurse note of 3/25/21 at 12:01 AM read, "Earlier today the patient had a fall that resulted in head strike....Grave prognosis. Patient now DNR (Do Not Resuscitate) and hospice to see." The patient was discharged to hospice care on 3/25/21. The patient died on [DATE] at 11:40 PM.

On 6/02/21 at 12:40 PM, Nurse Manager D from Surgical 2 unit stated that throughout the day of 3/24/21, prior to his fall, the bed alarm and TeleSitter alerted her and other staff to patient #1's attempts to get out of bed. She stated that she had entered his room at least 3 times in the morning.

On 6/03/21 at 10:45 AM, Registered Nurse (RN) B stated that during that day, the patient was actively and repeatedly trying to get out of bed.

On 6/02/21 at approximately 4:25 PM, Licesened Practical Nurse (LPN) E said she had been taking food to another patient when she heard the patient #1's alarm and subsequent fall. She stated she found the patient on the left side of his bed, somewhat on his side. She stated that all of the patient's bed siderails were up when she discovered the patient.

On 6/03/21 at 10:59 AM, Charge Nurse D stated she observed the patient periodically during the day moving his leg over the side of the bed.

On 6/03/21 at 11:17 AM, Patient Safety Attendant (TeleSitter) A stated that she observed full side rails just prior to the fall. She stated that she saw him on one occasion that day trying to get his right leg over the left side of the bed. She stated that in other instances, he would scoot to the bottom (foot) of the bed with arm assistance towards a gap at the foot of the bed, which was between the foot of the bed and the end of the lower side rail. She stated that the camera position faced the patient head-on, showing the entire bed. She stated that prior to the fall, she had noticed him scooting down and turned on the alarm. She stated that the patient got to a sitting position at the foot of the bed and then fell forward.

The hospital policy on restraints at the time of the fall, "Patient Restraint/Seclusion - COG.COG.001" revealed the following: "The hospital must report the following information to the CMS Regional Office. The hospital must report ....Each death known to the hospital that occurs within one week (days two through seven) after restraint or seclusion where it is reasonable to assume that use of restraint....Contributed directly or indirectly to a patient's death, regardless of the type(s) of restraint used on the patient during this time....Using side rails to prevent a patient from voluntarily getting out of bed would be considered a restraint....Disoriented patients may view a raised side rail as a barrier to climb over....or may scoot to the end of the bed to get around a raised side rail and exit the bed."

On 6/02/21 at 3:40 PM, the Vice President of Quality stated that a report of death in restraints was not reported to CMS as required.