HospitalInspections.org

Based on document review and interview, the governing body (GB) failed to be effective in ensuring the Quality Team carried out the responsibilities to mitigate risk factors associated with falls with injuries, and in carrying out its responsibilities for the conduct of the hospital's staff and ensure incidences of falls were thoroughly investigated and interventions developed to mitigate the risks of further falls. The GB failed to implement action plans for substantiated abuse and ensure all patients received care in a safe setting and failed to document in the GB meeting minutes process improvement strategies to reduce the risk of falls.

The failure of the Governing Body to mitigate risk factors associated with incidences of falls resulted in a condition level deficiency.

1. The Governing Body meeting minutes did not reveal any action plans, interventions or follow-up to ensure all patients in the hospital were free from falls with injuries and abuse.
Refer to A063.

2. Patient #1 was admitted to the hospital on 8/24/2020 for rehabilitation with diagnoses including Acute Left Middle Cerebral Artery Stroke, and Right Hemiplegia and Aphasias. Patient #1 fell while attempting to get out of bed to use the restroom on 8/25/2020. The patient's bed alarm had been turned off by staff. Staff found the patient crawling on the floor. The Registered Nurse (RN) who was in the room with the patient kicked his leg into the patient's side while the patient was crawling on the floor and told the patient to get back in the bed himself. This was witnessed by othe staff members. No new interventions were implemented following the abuse to ensure all patients were free from abuse. Patient #1 was a high risk for falls no preventative interventions were in use at the time of the fall.
Refer to A-144, A-145 and A-396.

3. Patient #2 was admitted to the hospital on 9/16/2021 for rehabilitation with diagnoses including Myopathy following COVID-19 Pneumonia. Patient #2 fell on 9/26/2021 and was found on the floor deceased. Patient #2 was high risk for falls. No preventative interventions were in use at the time of the fall. The time of the fall was unknown.
Refer to A-144 and A-396.
4. Patient #3 was admitted to the hospital on 8/27/2021 for rehabilitation with diagnoses including Toxic Myopathy associated with Streptococcal Pneumonia. Patient #3 fell on 8/30/2021 and sustained a head injury. Patient #3 was high risk for falls. No preventative interventions were in use at the time of the fall.
Refer to A-144 A-396.

5. Patient #4 was admitted to the hospital on 7/31/2021 for rehabilitation with diagnoses including Critical Illness Myopathy. Patient #4 fell on 8/6/2021 and sustained a head injury. Patient #4 was not classified as a fall risk at the time of the fall and the wheelchair alarm had been removed due to a falls re-assessment on 8/3/21 that determined Patient #4 no longer needed a wheelchair alarm. No interventions were in use at the time of the fall.
Refer to A-144, and A-396.

Based on policy review, document review, medical record review and interview, the hospital failed to ensure patient's rights were promoted to receive care in a safe setting for 4 of 4 (Patients #1, #2, #3 and #4) patients who fell while unattended and for 1 of 4 (Patient #1) who was physically and mentally abused by a staff member.

The findings included:

1. Patient #1 was admitted to the hospital on 8/24/2020 for rehabilitation with diagnoses including Acute Left Middle Cerebral Artery Stroke, and Right Hemiplegia and Aphasias. Patient #1 fell on 8/25/2020 while attempting to go to the bathroom by himself. Patient #1 did not sustain any injuries however Patient #1 was the victim of physical and verbal abuse by registered nurse (RN) #3 while the patient was crawling on the floor attempting to get back into bed. It was determined the patient's bed alarm had been deactivated. Patient #1 was high risk for falls. No preventative interventions were in use at the time of the fall. There was no documentation of new interventions put into place to prevent falls and no documentation of new interventions put into place to prevent abuse.
Refer to A-144, and A-145

2. Patient #2 was admitted to the hospital on 9/16/2021 for rehabilitation with diagnoses including Myopathy following COVID-19 Pneumonia. Patient #2 fell on 9/26/2021 and was found on the floor deceased. Patient #2 was high risk for falls. No preventative interventions were in use at the time of the fall. The time of the fall was unknown. The patient's bed alarm had been deactivated. There were no new interventions put into place following the patient's fall and for the deactivation of the patient's bed alarm.
Refer to A-144.

3. Patient #3 was admitted to the hospital on 8/27/2021 for rehabilitation with diagnoses including Toxic Myopathy associated with Streptococcal Pneumonia. Patient #3 fell on 8/30/2021 and sustained a head injury and a fractured hip. Patient #3 was high risk for falls. No preventative interventions were in use at the time of the fall. Patient #3's bed alarm had been deactivated. There was no documentation of new interventions put into place following Patient #3's fall, and for the deactivation of the patient's bed alarm.
Refer to A-144.

4. Patient #4 was admitted to the hospital on 7/31/2021 for rehabilitation with diagnoses including Critical Illness Myopathy. Patient #4 fell on 8/6/2021 and sustained a head injury. Patient #4 was not classified as a fall risk at the time of the fall. The wheelchair alarm had been removed due to a falls re-assessment on 8/3/2021 that determined Patient #4 no longer needed a wheelchair alarm., although according to the hospital policy the patient met the need for a chair alarm. No interventions were in use at the time of the fall.
Refer to A-144.

Based on policy review, document review, medical record review and interview, the hospital failed to have an organized nursing service which ensured interventions were developed and implemented to prevent falls for 4 of 4 (Patients #1, #2, #3, and #4) patients who fell while unattended and for 1 of 4 (Patient #1) who was physically and mentally abused by a staff member.

The findings included:

1. Patient #1 was admitted to the hospital on 8/24/2020 for rehabilitation with diagnoses that included Acute Left Middle Cerebral Artery Stroke, and Right Hemiplegia and Aphasias. Patient #1 was at high risk for falls. Patient #1's fall alert alarms were turned off by staff. Patient #1 attempted to go to the bathroom unattended and fell. Patient #1 did not sustain any injuries from the unwitnessed fall. While Patient #1 was on the floor, RN #1 was observed to have kicked Patient #1's side. There were no preventative fall interventions in place at the time of Patient #1's fall. There were no interventions in place to prevent abuse.
Refer to A-396

2. Patient #2 was admitted to the hospital on 9/16/2021 for rehabilitation with diagnoses including Myopathy following COVID-19 Pneumonia. Patient #2 had an unwitnessed fall on 9/26/2021 and was found on the floor deceased. The actual time of the fall was unknown. There were no preventative interventions in place when Patient #1 fell. The bed alarm was turned off at some time prior to the time of Patient #2's fall.
Refer to A-396

3. Patient #3 was admitted to the hospital on 8/27/2021 for rehabilitation with diagnoses including Toxic Myopathy associated with Streptococcal Pneumonia. Patient #3 was a high risk for falls and had no preventative interventions in place on 8/30/21. Patient #3 fell and sustained a head injury on 8/30/2021. This was an unwitnessed fall. Patient #3's bed alarms were inactivated prior to the fall and there was no documentation of new interventions put into place following the fall.
Refer to A-396

4. Patient #4 was admitted to the hospital on 7/31/2021 for rehabilitation with diagnoses including Critical Illness Myopathy. Patient #4 was not classified as a fall risk at the time of the fall. Patient #4 was assessed as a fall risk upon admission. Patient #4 was re-assessed 3 days later and was determined not a fall risk. The chair alarm was removed. There were no interventions in place at the time of the fall.
Refer to A-396

Based on policy review, document review and interview, the Governing Body (GB) failed to assume responsibility, provide oversight and provide clear documentation in the Governing Body meeting minutes, to ensure action plans for falls were developed, implemented, monitored and measured to prevent further falls by documenting measurable improvement in the safety for all patients at risk for falls including 4 of 4 (Patients #1, #2, #3 and #4) patients who fell without interventions in place to prevent falls. The GB failed to assume responsibility and ensure all patients were free from all forms of abuse for 1 of 4 (Patient #1) who was physically and mentally abused by by a Registered Nurse (RN).

The findings include:

1. Review of the hospital's Fall Prevention Program Policy revealed, "...The Fall Team is responsible for...Analyzing data and trending information and making recommendations to...Governing Body...on ways to improve patient safety and decrease falls in the hospital..."

2. Review of the hospital's Quarterly (First Quarter: January, February, March, 2021) Quality Council (Quality Assurance Process Improvement: QAPI) meeting minutes dated 5/6/2021 revealed, "...RCA [Root Cause Analysis] Audits...Fall Prevention...No falls related to inadequate transfers in Q1 [1st Quarter]..."
The Fall Team reported total falls per 1000 patient days for January, February and March.
There was no documentation in the minutes the Fall Team reported any specific patient falls with injuries to the Governing Body or made recommendations to the Governing Body ways to improve patient safety and decrease falls in the hospital.
The leading locations of patient falls was "from wheelchair, from bed...TARGET DATE 6/1/21 [2021]...FOLLOW-UP...Will report to...GB [Governing Body]..."
The QAPI meeting minutes revealed no additional discussion or documentation regarding action plans implemented to mitigate the risks of further patient falls.
There was no documentation regarding specific patients that fell with injuries from the Quality Assurance Process Improvement meeting minutes. There was no documentation the GB discussed patient abuse or interventions to ensure all patients were free from all forms of abuse.

3. Review of the Governing Body meeting minutes dated 6/1/2021 revealed the exact same verbiage as the QAPI meeting minutes dated 5/6/2021. The Governing Body meeting minutes revealed, "..FOLLOW-UP...Reported to GB..."

The GB meeting minutes revealed no additional discussion or documentation regarding action plans implemented to mitigate the risks of further patient falls.

There was no documentation the GB discussed patient abuse or interventions to ensure all patients were free from all forms of abuse.

4. Review of the hospital's Quarterly (Second Quarter: April, May, June, 2021) Quality Council (QAPI) meeting minutes dated 8/5/2021 revealed, "...RCA [Root Cause Analysis] Audits...Fall Prevention: "...No falls related to inadequate transfers in Q2 [2nd Quarter]...Fall Prevention Program reviewed with all staff during staff meetings...Post fall investigation huddles completed daily to increase critical thinking and problem solving..."
The Fall Team reported total falls per 1000 days for April, May and June. There was no documentation in the minutes the Fall Team reported any specific patient falls with injuries to the Governing Body or made recommendations to the Governing Body ways to improve patient safety and decrease falls in the hospital.
The leading locations of patient falls was from "toilet/commode, wheelchair, unknown/found on floor...TARGET DATE 8/20/21 [2021]...FOLLOW-UP...Will report to...GB..."
The QAPI meeting minutes revealed no additional discussion or documentation regarding action plans implemented to mitigate the risks of further patient falls.
There was no documentation regarding specific patients that fell with injuries from the Quality Assurance Process Improvement meeting minutes.
There was no documentation the GB discussed patient abuse or interventions to ensure all patients were free from all forms of abuse.

5. Review of the Governing Body meeting minutes dated 8/20/2021 revealed the exact same verbiage as the QAPI meeting minutes dated 8/5/2021. The Governing Body meeting minutes revealed, "...FOLLOW-UP...Reported to GB..."

The GB meeting minutes revealed no additional discussion or documentation regarding action plans implemented to mitigate the risks of further patient falls.
There was no documentation the GB discussed patient abuse or interventions to ensure all patients were free from all forms of abuse.

During an interview with the Chief Executive Officer (CEO) and the Chief Nursing Officer (CNO) on 10/13/2021 beginning at 1:30 PM, the CEO confirmed the QAPI meeting minutes and the GB meeting minutes does not contain documentation or discussion that details the action plans, interventions, or monitoring that confirms the committee(s) are actively involved with process improvement related to falls.
The CEO confirmed better communication and documentation was needed. The CEO and CNO were asked about the meeting minutes being identical from each of the meetings. The CNO revealed each meeting is independent and the audiences are different.
Refer to A-144 and A-145.

Based on policy review, document review, medical record review and interview, the hospital failed to ensure patients' rights were promoted and all patients received care in a safe setting when chair/bed alarms were de-activated by staff for 4 of 4 (Patients #1, #2, #3 and #4) patients who fell while unattended with their chair of bed alarm deactivated by staff.

The findings include:

1. Review of the hospital policy "Fall Prevention Program" last revised 6/2/2020 revealed, "...An unwitnessed Fall is a type of fall that is unobserved by staff, including falls reported by the patient, family, another person or visitor...All falls will be assigned a severity level...Major Injury: bone fracture, joint dislocation, closed head injury with altered consciousness, or subdural hematoma...The evidenced based risk screening tool used is the [Named Fall Risk Scale]...Totaled scores > 45 indicates a risk of falling at a basic level; Additional assessment information will be used to determine high level...Additional considerations for fall risk are found in assessments and evaluations conducted in nursing and therapy including, but not limited to, those evaluating cognition, mobility and balance...Care Planning Patients scoring higher than 45 on the Morse Scale (Fall Risk Scoring System) are considered at risk for falls...An RN [Registered Nurse] will determine an initial level (basic or high) based on clinical judgment, hospital scoring levels, and other assessments. Interventions and goals will be initiated based on risk level, individualized to the patient's needs. As therapy evaluations are conducted, indicating the need for additional goals and interventions, they will be added to the Falls IPOC [Interdisciplinary Plan of Care]. This plan can be modified by an RN, PT [Physical Therapy], OT [Occupational Therpy], or SLP [Speech Language Therapy] at anytime during the stay based on the determination of need for change...Intervention Strategies...should be based on level of risk identified through assessment and evaluation and the individual needs of the patient. All patients receive standard fall prevention measures such as beds in low position, wheelchair brakes locked, call light within reach, etc. A patient's level of fall risk will be communicated to the interdisciplinary team via visual cues in the room, the medical record, and patient identifier. These cues will be described in the procedure section below. Interventions for Basic or High risk levels may include any of the following:
Basic Level:
Bed Alarm Basic Level/Zone 1
Chair Alarm
Self releasing Seatbelts
Wheelchair positioning aids
Toilet before leaving in room alone
Toilet patient before giving high risk fall medications
Diversional Activities

High Risk: (any of the above plus the following)
Bed Alarm Level/Zone 2
Bed Alarm Level/Zone 3
Low Bed
Supervision in bathroom (stay with me)
Supervision at all times
1:1 Handoff
Bedside perimeter mats
Toileting schedule
Pharmacy medication review...
PROCEDURE...All patients are assessed for fall risk as part of the Nursing admission process by a registered nurse using the Morse Fall Risk Assessment...Patients who score less than 25 will be considered at low risk...Patients who score 25-45 are considered a moderate fall risk...Patients score >45 are considered a high fall risk..."

In an e-mail on 10/5/2021 at 1:30 PM, the Director of Quality/Risk (DQR) documented, "...We do not have a separate policy just for bed alarms. We have a fall precaution policy..."

2. Medical record reviewed revealed Patient #1 was 50 years old and admitted to the hospital on 8/24/2020 with a diagnoses including an Acute Left Middle Cerebral Artery Stroke, and Right Hemiplegia and Aphasias. Patient #1 was to have a bed alarm.

Review of the physician progress notes on 8/25/2020 revealed,"...Patient had fall [fallen] in the room this morning attempting to get to the bathroom by himself, no injuries...".

Review of the nurses progress notes on 8/25/2020 at 5:11 PM revealed, "...Nurse informed sister that pt [Patient #1] had a fall on night shift without any injuries. sister was upset because no one phoned her to let her know about the incident. Sister requested to speak with someone in charge...Nurse informed supervisor of sister's request..."

Review of the written statement from the DQR dated 8/25/2020 revealed, "While investigating the situation surrounding [Named Patient #1] fall...spoke with [Patient #1]...said that he walked to the bathroom because his pull up was wet. When trying to reach for the light, he fell from the toilet..."

Review of a telephone conversation between the Human Resource Director (HRD) and RN #3 dated 8/26/2020 at 11:50 AM revealed RN #3 stated when Patient #1 was found in the floor the patient's diaper was falling off because "it was so full".

Review of a written statement from Witness #3 who found Patient #1 on the floor revealed, "...I wanted to inform you of an incident that occurred on 8-25-2020 at approximately 0440 [4:00 AM]...The bed alarm was not on. [RN #3] turned it on when I [Witness #3] was in the room. I [Witness #3] told Witness #1 that I [Witness #3] wanted to talk to her...Witness #1 said earlier that [RN #3] had said that he had turned the bed alarms off in some of his rooms intentionally..."

There was no documentation of new interventions following the fall of Patient #1 or interventions to ensure all patients' bed alarms were activated and not intentionally turned off by staff.

3. Patient #2 was a 68 year old admitted to the hospital on 9/16/2021 for rehabilitation with diagnoses including Myopathy following COVID-19 Pneumonia.

A Fall Risk assessment was completed on 9/17/2021 and Patient #2 was assessed to be high risk for falls. Patient #2 was put on a bed alarm.

On 9/25/21 at 10:41 AM the medical record revealed Patient #2 had assistance with a bowel movement.

Review of the staff's rounding notes for Patient #2 revealed the last time the patient was rounded on and checked for any needs was at 4:04 PM.

At 9:52 PM, the Medication Administration Report revealed Patient #2 received medication.

At 10:06 PM Patient #2's vital signs were taken. No other assessments of patient needs were identified at this time.

On 9/26/2021 at 4:50 AM, a staff member went into Patient #2's and found the patient deceased on the floor. The patient's bed alarm was noted to be de-activated.

During an interview on 10/6/2021 at 9:30 AM the DQR confirmed patient rounding should have been done every 2 hours. The DQR confirmed the Agency Technician responsible to check on Patient #2 assigned had been found asleep during her shift on two (2) separate occasions and no interventions had been implemented each time the staff had been found asleep. The DQR stated communication was not adequate that night.

During an interview on 10/6/2021 at 2:58 PM the Chief Nursing Officer (CNO) was asked who was responsible to make sure patients' bed alarms were turned on and the CNO stated, "The last person who got the patient up should have reactivated it...we were short staffed that night."
The CNO stated if the night supervisor had been assigned patients they would have been adequately staffed. The CNO stated it was at the night supervisor's discretion to take assignment of patients.
The CNO was asked what interventions have been implemented to ensure patients bed alarms were activated and the CNO stated there was a 12 bed audit every night that the night supervisor had done, and also education for the staff if the bed alarms are found turned off.
The CNO was asked if she felt there had been non compliance with the bed alarms prior to this incident and the CNO stated, " yes" and verified there was no documentation of action plans for the return demonstration of knowledge of bed alarms.
The CNO and DQR was asked how mental status is determined on the Morse Fall Score. The CNO stated they use the BIMS (Brief Interview for Mental Status) scoring system. A BIMS score of 12 and below gets a mental status score of 15 on the Morse Fall Risk Score.

During an interview on 10/7/2021 at 7:15 AM, in the conference room RN #1 was asked how Patient #2's bed alarm got turned off and why was it turned off and RN
#1 stated, "...I don't know how the bed alarms got turned off...there are no bed alarms on if they [patients] are not a fall risk".
RN #1 was asked if Patient #2 was a fall Risk and RN #1 did not give an answer.

During an interview on 10/7/2021 at 8:06 AM the Night Supervisor was asked about the incident that happened on 9/25/2021 on the night shift with Patient #2 and the Night Supervisor stated, "...[Patient #2] was lying in the floor...on the left side with a pool of blood...lying on his left side. [Patient #2] was a full code...he had no pulse and was not breathing...I looked at the clock, it was 4:50 AM [9/26/2021]...When I looking around I was in the room by myself...I brought the crash cart in the room got the Ambu bag I told [Named RN #2] to call 911 and the Administrator on call...[Named RN #2] called to the Administrator on call [AOC] and then I talked to [Named AOC] he asked have you called the doctor....When [named Emergency Medical Services] was here Patient #2 was dead, they had wrapped him up in a sheet. The patient was dead when EMS got here. It looked so to me there was no heart rate, no respiratory and he was pale in my opinion he was dead..."

During an interview on 10/12/2021 beginning at 2:35 PM, the CNO, DQR confirmed Patient #2's bed alarm was not activated. The DQR stated they were made aware during the investigation that the agency tech stated she was not educated how to re-set the bed alarms. The DQR stated the agency tech stated she was only taught how to turn the alarm off. The DQR stated a root cause analysis was done and several things were discovered such as a lack of communication and adequate training for new hires. The DQR stated bed alarm use needed additional training with return demonstrations. The DQR stated there were many things put into place after this fall that they are focusing on. The CNO stated "staffing was an issue..."
The CNO was asked what was done when short staffed and the CNO stated the night supervisor would take an assignment of patients. The CNO was asked if the night supervisor had taken an assignment of patients on 9/25/2021 - 9/26/2021 and the CNO confirmed the night supervisor had not taken an assignment of patients.

Review of the assignment sheet for 9/25/2021 - 9/26/2021 for the 7:00 PM to 7:00 AM shift revealed no documentation the night supervisor had taken an assignment of patients.

4. Patient #3 was a 79 year old admitted to the hospital on 8/27/2021 for rehabilitation with diagnoses including Toxic Myopathy associated with Streptococcal Pneumonia.

Patient #3 was assessed as a high fall risk on 8/30/2021 at 9:33 AM.

Patient #3 had an unwitnessed fall on 8/30/2021 and was found on the floor at 11:15 PM and sustained a head injury.

The physician was notified with no new orders identified in the medical record.

No physician progress notes were identified related to Patient #3's injuries post fall.

Review of Patient #3's post fall assessment on 8/30/2021 at 11:52 PM revealed Patient #3 had a major fall injury. The activity at the time of the fall was unknown. The patient was found on the floor by the Rehabilitation Nurse Technician (RNT). Patient was unsure where she was going at the time and did not use the call light for assistance. Patient #3 was assisted to the wheelchair per staff without any issue. Patient #3 was assessed and an abnormality was found to the head which was documented as, "...Round, edematous area noted to left forehead present on assessment that is 4.5 cm [centimeters]...Denies any pain at site on assessment. No drainage or opening present..." An assessment of Patient #3's lower extremities revealed the right and left lower extremities moved against gravity, the tone was normal and sensation was intact. A neurological assessment was completed on 8/30/2021 at 11:15 PM which was documented as neurologically intact. There were no other assessments completed on Patient #3.

Review of Patient #3's Medication Administration Record (MAR) revealed acetaminophen 650 milligrams (mg) was administered on 8/31/2021 at 1:36 AM for patient complaints of lower leg pain with a pain score of 8 on a scale of 1 - 10 with 10 being the most severe.
There was no documentation the physician was notified about Patient #3's pain level.

On 8/31/2021 at 7:31 AM Patient #3 was administered acetaminophen 650 mg for lower leg pain with a pain score of 10. There was no other documentation of the assessment of the patient's pain.

A nursing progress note dated 8/31/2021 at 10:17 AM revealed, "...on assessment patient c/o [complained of] left hip thigh pain 10/10 [highest level of pain on the pain scale], requesting pain medication, patient states that she is unable to straighten it [her leg]or bear weight after fall last night, left scalp hematoma noted as well...notified [Named RN Supervisor] to contact [Named Physician] regarding left hip pain and change in mobility..."

Patient #3 was transferred out to the acute care hospital per physician's order for worsening pain and inability to bear weight.

Review of the acute care hospital record revealed on 8/31/2021 Patient #3 was admitted with left hip fracture and a left frontal hematoma.

During an interview on 10/12/2021 beginning at 2:35 PM, the CNO and DQR stated that Patient #3 was not wearing grip socks as needed and confirmed the bed alarm was not activated. The CNO and DQR confirmed Patient #3 was transferred out to the local acute care hospital on 8/31/2021 at 8:11 AM due to inability to bear weight and worsening pain. The CNO and DQR confirmed Patient #3 had a left hip fracture and underwent surgery on 8/31/2021 for femoral head repair after getting the report from the acute care hospital. The CNO confirmed re-assessment education was needed.

5. Patient #4 was 74 years old and admitted to the hospital on 7/31/2021 for rehabilitation with diagnoses including Critical Illness Myopathy.

Patient #4 was assessed as a high fall risk on 7/31/2021 with a Morse Fall Risk Score of 50.

On 8/3/2021 Patient #4 was re-assessed with a Morse Fall Risk Score of 40. According to the Fall Prevention Policy Patient #4 was a moderate fall risk with a score of 40. Even though Patient #4 was a moderate fall risk according to the policy, there were no interventions put in place to prevent falls for Patient #4.

Review of a Physical Therapy (PT) Daily Documentation dated 8/6/2021 at 1:00 PM revealed, "...Exercise #1 Comment...B [bilateral] LE [Lower Extremities] heelraises, toe raises...seated hip flexion. All performed to increase LE strength to aid in functional mobility. Pt requires prolonged rest breaks due to fatigue...Assessment...Impairments/Limitations-PT: Impaired gait, bed mobility deficits, Impaired activity tolerance. Range of motion deficits, strength deficits, Transfer deficits, Wheelchair mobility deficits...Total Individual Minutes 90..."
This PT session began at 1:00 PM and ended at 2:30 PM and Patient #4 was taken back to her room and left unattended in the wheelchair.

On 8/3/2021 at 2:40 PM Patient #4 was found on the floor in front of her wheelchair. This was ten (10) minutes after being left in the wheelchair in her room unattended.

Review of the hospital investigation revealed Patient #4 stated she got up from her wheelchair to plug in her cell phone and fell and hit her head.

The hospital did not follow their Fall Prevention Policy when Therapy notes were not taken into consideration when Patient #4 was assessed for a fall risk.

During an interview on 10/12/2021 beginning at 2:35 PM, the CNO and DQR were asked about the use of a wheelchair alarm for patients with a Morse Fall score of 40 and the CNO stated there was a seat alarm decision tree that the staff used as a guide.

The Seat Alarm Decision Tree revealed the following:
Is the Morse Fall Score >45?
IF YES:
The Patient requires a seat alarm.
IF NO:
Does the patient display any of the following?
communication deficit
incontinence
altered mental status
impulsivity
IF YES:
The patient requires a seat alarm.
IF NO:
Patient does not require a seat alarm.
End of decision tree.

The CNO confirmed this practice is not documented in the Fall Prevention Policy, it is just what they do in this hospital.

Based on policy review, document review, medical record review, and interview, the hospital failed to ensure administration and supervisors followed the abuse policy by failing to remove any immediate threats of abuse and failed to ensure measures were developed and implemented following the substantiated abuse of a patient to ensure further abuse would not occur for 1 of 1 (Patient #1) patients reviewed who was abused by a staff member and for all patients in the hospital.

The findings include:

1. Review of the hospital's policy titled Allegations of Abuse/Neglect dated 6/13/2019 revealed, "...Hospital staff will take all necessary steps to ensure that patients are kept safe from abuse/neglect and that allegations of abuse/neglect by employee or visitors are investigated promptly, thoroughly, and reported to the proper authorities as necessary. The immediate response of staff will be guided by whether there has been a witnessed/confirmed act of abuse/neglect or whether there have reports or suspicions of abuse/neglect that have not been witnessed/confirmed. All clinical and non-clinical staff must be trained on how to report substantiated/suspected abuse/neglect...Witnessed/Confirmed Acts of Abuse/Neglect...Take immediate action to protect the patient from further harm...Unit staff must contact their supervisor and or a supervisor on duty immediately upon notification of allegation/findings of any form of abuse/neglect...The supervisor must immediately notify the hospital CEO [Chief Executive Officer]/CNO [Chief Nursing Officer] designee...The patient must be...examined immediately for injury, treated, if necessary, secured from further harm by taking any additional actions to ensure the patient's safety and welfare...reassigning staff and/or suspending accused staff pending investigation..."

2. Review of the hospital's policy titled Recognition and Reporting of Suspected Abuse or Neglect dated 3/12/2020 revealed, "...To provide guidelines for the recognition and reporting of suspected patient abuse or neglect...Any clinician that discovers or suspects that a patient has potentially been abused, neglected, exploited...will immediately notify the supervisor on duty...The following information will be provided to the supervisor and the treating physician...Clinical basis for reason to suspect abuse/neglect...any additional knowledge that supports the suspected abuse/neglect...immediate safety needs of the patient will be considered and safety measures implemented as needed...Documentation: screening for potential indicators...physical assessment findings...any other information that forms the basis of a suspicion of abuse/neglect...The date, time and method of reporting to the appropriate agency, the name of the agency and individual that received the report should be documented in the patient's medical record...All clinical employees will receive training on the recognition of abuse/neglect upon hire and annually at the minimum..."

3. Medical record reviewed revealed Patient #1 was admitted to the hospital on 8/24/2020 with a diagnoses including an Acute Left Middle Cerebral Artery Stroke, and Right Hemiplegia and Aphasias.

Review of the physician progress notes on 8/25/2020 revealed,"...Patient had fall [fallen] in the room this morning attempting to get to the bathroom by himself, no injuries...".

Review of the nurses progress notes on 8/25/2020 at 5:11 PM revealed, "...Nurse informed sister that pt [Patient #1] had a fall on night shift without any injuries. sister was upset because no one phoned her to let her know about the incident. Sister requested to speak with someone in charge...Nurse informed supervisor of sister's request..."

Review of a written statement from Witness #3 revealed, "...I wanted to inform you of an incident that occurred on 8-25-2020 at approximately 0440 [4:00 AM] [Named Room Number] involving RN #3. Witness #1 and Witness #2 came into [room where Witness #3 was at] where I was and said that they needed assistance immediately in [Named Room Number] that the pt. [Patient #1] had fallen but was unharmed. Witness #1 was visibly upset and shaking and appeared that she was going to cry. I [Witness #3] immediately went out of the [current patient's room] and asked what was wrong. Witness #1 said that [RN #3] was in her opinion mistreating [Patient #1] by the way RN #3 was talking to the patient in an angry tone and that [RN #3] had used his foot to keep pressing against the pt's [Patient #1's] leg telling him to get up while raising his voice. I [Witness #3] immediately asked the pt. [Patient #1] if he was hurt an he said no. I [Witness #3] told [RN #3] to get the vital signs and assess the pt. [RN #3] told Witness #1 and #2 to get a sheet and lift the pt. [Patient #1] up into the bed. We decided it would be in the best interest of the staff and pt. [Patient #1] to get a [Named Battery Operated Lift] to get the pt. [Patient #1] up which is what we did. The bed alarm was not on. [RN #3] turned it on when I [Witness #3] was in the room. I [Witness #3] told Witness #1 that I [Witness #3] wanted to talk to her...Witness #1 said earlier that [RN #3] had said that he had turned the bed alarms off in some of his rooms intentionally and that she [Witness #1] felt that [RN #3] had mistreated the pt. [Patient #1]. I [Witness #3] told her [Witness #1] to please contact the CNO this am which she said she would. I asked [RN #3] if he had turned the alarms off on any of his beds last night and he [RN #3] said no, however, the bed alarm did not go off in this pt's [Patient #1's] room...I [Witness #3] called the Quality/Risk Director this am to let her know what had occurred..." After the alleged abuse by RN #3 towards Patient #1, the hospital staff allowed RN #3 to assess Patient #1 for signs of injury.

During a telephone interview on 9/23/2021 at 7:40 AM ,Witness #3 (the night supervisor) was asked to verify that her typed statement was accurate. Witness #3 verified the statement was accurate and confirmed it was written on 8/25/2021. Witness #3 was asked if she instructed RN #3 to obtain vital signs and do an assessment on Patient #1 after being told of the alleged abuse by RN #3 and Witness #3 stated, "Yes..."
Witness #3 was asked if she reassigned Named RN #3 after going into the patient's room and being told by Witness #1 and #2 of the alleged abuse. Witness #3 stated "No, I instructed Named RN #3 not to go into the room unless someone was with him and to keep the door open. Witness #3 was asked what time did she call the Director of Quality/Risk (DQR) to report the incident. Witness #3 stated, "I don't recall the time I just know it was in the morning..."

Review of the written statement from the DQR dated 8/25/2020 revealed, "While investigating the situation surrounding Named Patient #1 fall in [named room number], I [DQR] spoke with patient [Patient #1]". The DQR documented she reviewed Patient #1's medical records which revealed Patient #1 had difficulty with "word-finding" and "jargon interfered with patient's ability to communicate functional needs". The DQR documented, "When I spoke with [Patient #1] today, [Patient #1] definitely struggled with work finding and it took extra time, but [Patient #1] was able to describe the situation. [Patient #1] said that he walked to the bathroom because his pull up was wet. When trying to reach for the light, he fell from the toilet. When the nurse, [RN #3] entered the room, Patient #1 stated [RN #1] yelled to get up. [Patient #1] said he tried but was unable to get up. [RN #3] was nudging Patient #1 with his foot as RN #3 was telling Patient #1 to get up, which Patient #1 said that hurt. When I asked for clarification, [Patient #1] showed me that RN #3 was pushing on him with his foot. [Patient #1] said [RN #3] did not kick him, but again repeated to RN #3 that it hurt, and [Patient #1] told the nurse that. [Patient #1] also reports that [RN#3] apologized to him after the incident..."

During an interview on 9/28/2021 beginning at 11:52 AM, the DQR was asked to verify if her typed statement was accurate. The DQR verified the statement was accurate and confirmed it was written on 8/25/2020.

Review of the hospital's written telephone interview with RN #3 and the Human Resource Director (HRD) on 8/26/2020 at 11:13 AM revealed, "... [RN #3] stated that patient [Patient #1] was found in the floor by Witness #1. Stated that patient denied falling. [RN #3] stated that he was just trying to get patient back to bed, but patient was too big. [RN #3] said that he told [Patient #1] that he was gonna have to help and stated "Come on man" RN #3 denied any wrong doing. [RN #3] called back at 11:50 AM on 8/26/2020. [RN #3] stated that when Patient #1 was found, [Patient #1] had a diaper on that was falling off because it was so full. [RN #3] told [Witness #1] that if [Witness #1] had been making rounds the patient wouldn't of fallen. [RN #3] stated that he made the tech [Witness #1] mad so she is retaliating against him because he [RN #3] call her [Witness #1] out. When asked if the bed alarm was on [RN #3] stated that it was when he passed meds. [RN #3] was asked if a post fall assessment was completed, he said yes under nurse notes, when patient chart was reviewed there was no record of assessment. Family also was not contacted by [RN #3]..."

During a telephone interview on 9/28/2021 at 2:25 PM, RN #3 was asked to verify his written telephone statement given to the HRD and RN #3 stated, "...Stop right there...I've already been to court over this and it was dismissed. I have a lawyer and if you need anything you can contact my lawyer and you can contact the Board of Nursing to get his name...I have no comment do you understand Comprende..."

The Personnel file was reviewed for RN #3 which revealed a form titled Separation Notice which documented RN #3's last day of employment at the hospital was 8/28/2020 due to violation of hospital policy.

During a telephone interview on 9/29/2021 at 10:26 AM, the Human Resource Director (HRD) was asked if after substantiating the abuse by RN #3 to Patient #1 had any abuse inservices, re-education or any other action plans been implemented to prevent any further abuse of patients and the HRD stated, "No, after our investigation we felt like if was an isolated incident our employees were the ones that told us about it...The employees receive inservices about Abuse/Neglect in orientation and annually..."

In an e-mail correspondence on 9/30/2021 beginning at 9:25 AM, the HRD was asked who the Administrator on Call was on the night of the abuse of Patient #1 and the HRD stated she was the Administrator on call and was not contacted at the time of the incident. The HRD stated she was notified in the morning shift report and an investigation began at that time. The HRD was asked if RN#3 completed working the assigned shift or was RN #3 reassigned, and the HRD stated, "...[RN #3] did complete his shift..."

The hospital failed to ensure that hospital administration and supervisors followed hospital policy to keep patients safe. Hospital staff reported the abuse immediately to supervisors. The hospital failed to follow the abuse prevention policy and ensure all necessary steps were taken to keep patients safe and free from abuse. The night Supervisor failed to follow the abuse policy and immediately report to the Chief Executive Officer, Chief Nursing Officer and/or the Administrative personnel on call the witnessed abuse of Patient #1. After the report of the witnessed abuse by RN #3 to Patient #1, RN #3 was asked to perform an assessment of the patient by the supervisor. The hospital identified the incident as an isolated and no re-education of abuse or other abuse interventions were developed or implemented by the hospital to ensure all patients remained free from all forms of abuse.

Based on policy review, document review, medical record review and interview, nursing services failed to ensure nursing staff provided care to meet each patient's needs who were a fall risk for 4 of 4 (Patients #1, #2, #3, and #4) patients who fell and failed to ensure nursing staff provided a safe environment for 1 of 1 (Patient #1) patients who was abused by a staff member.

The findings included:

1. Review of the hospital policy "Fall Prevention Program" last revised 6/2/2020 revealed, "...The evidenced based risk screening tool used is the [Named Fall Risk Scale]...Totaled scores > 45 indicates a risk of falling at a basic level; Additional assessment information will be used to determine high level...Additional considerations for fall risk are found in assessments and evaluations conducted in nursing and therapy including, but not limited to, those evaluating cognition, mobility and balance...Patients scoring higher than 45 on the Morse Scale (Fall Risk Scoring System) are considered at risk for falls...An RN [Registered Nurse] will determine an initial level (basic or high) based on clinical judgment, hospital scoring levels, and other assessments. Interventions and goals will be initiated based on risk level, individualized to the patient's needs. As therapy evaluations are conducted, indicating the need for additional goals and interventions, they will be added to the Falls IPOC [Interdisciplinary Plan of Care]. This plan can be modified by an RN, PT [Physical Therapy], OT [Occupational Therpy], or SLP [Speech Language Therapy] at anytime during the stay based on the determination of need for change...Intervention Strategies...should be based on level of risk identified through assessment and evaluation and the individual needs of the patient. All patients receive standard fall prevention measures such as beds in low position, wheelchair brakes locked, call light within reach, etc. A patient's level of fall risk will be communicated to the interdisciplinary team via visual cues in the room, the medical record, and patient identifier...PROCEDURE...All patients are assessed for fall risk as part of the Nursing admission process by a registered nurse using the Morse Fall Risk Assessment...Patients who score less than 25 will be considered at low risk...Patients who score 25-45 are considered a moderate fall risk...Patients score >45 are considered a high fall risk..."

In an e-mail on 10/5/2021 at 1:30 PM, the Director of Quality/Risk (DQR) documented, "...We do not have a separate policy just for bed alarms. We have a fall precaution policy..."

2. Review of the hospital's policy titled Allegations of Abuse/Neglect dated 6/13/2019 revealed, "...Hospital staff will take all necessary steps to ensure that patients are kept safe from abuse/neglect...All clinical and non-clinical staff must be trained on how to report...Witnessed/Confirmed Acts of Abuse/Neglect...Take immediate action to protect the patient from further harm...The patient must be...examined immediately for injury, treated, if necessary, secured from further harm by taking any additional actions to ensure the patient's safety and welfare...reassigning staff and/or suspending accused staff pending investigation..."

3. Patient #1 was 50 years old, admitted to the hospital on 8/24/2020 with a diagnoses including an Acute Left Middle Cerebral Artery Stroke, and Right Hemiplegia and Aphasias. Patient #1 was high risk for falls.

Review of the physician progress notes on 8/25/2020 revealed,"...Patient had fall [fallen] in the room this morning attempting to get to the bathroom by himself, no injuries..."
Patient #1 was not assisted with toileting.

Review of the written statement from the DQR dated 8/25/2020 revealed, "...spoke with [Patient #1]...said that he walked to the bathroom...When trying to reach for the light, he fell from the toilet..."

Review of a written statement from Witness #3 revealed, "...The bed alarm was not on. [RN #3] turned it on when I [Witness #3] was in the room...Witness #1 said earlier that [RN #3] had said that he had turned the bed alarms off in some of his rooms intentionally..."

Review of the hospital's written telephone interview with RN #3 and the Human Resource Director (HRD) on 8/26/2020 at 11:13 AM revealed, "...[RN #3] stated that patient [Patient #1] was found in the floor by Witness #1. Stated that patient denied falling. [RN #3] stated that he was just trying to get patient back to bed, but patient was too big. [RN #3] said that he told [Patient #1] that he was gonna have to help and stated "Come on man" RN #3 denied any wrong doing. [RN #3] called back at 11:50 AM on 8/26/2020. [RN #3] stated that when Patient #1 was found, [Patient #1] had a diaper on that was falling off because it was so full. [RN #3] told [Witness #1] that if [Witness #1] had been making rounds the patient wouldn't of fallen...When asked if the bed alarm was on [RN #3] stated that it was when he passed meds. [RN #3] was asked if a post fall assessment was completed, he said yes under nurse notes, when patient chart was reviewed there was no record of assessment. Family also was not contacted by [RN #3]..."

There was no documentation of new interventions developed and implemented following the fall of Patient #1.

Review of a written statement from Witness #3 revealed, "...I wanted to inform you of an incident that occurred on 8-25-2020 at approximately 0440 [4:00 AM] [Named Room Number] involving RN #3...Witness #1 said that [RN #3] was in her opinion mistreating [Patient #1] by the way RN #3 was talking to the patient in an angry tone and that [RN #3] had used his foot to keep pressing against the pt's [Patient #1's] leg telling him to get up while raising his voice...and...felt that [RN #3] had mistreated the pt. [Patient #1]..."
After the alleged abuse by RN #3 towards Patient #1, the hospital staff allowed RN #3 to assess Patient #1 for signs of injury.

During a telephone interview on 9/23/2021 at 7:40 AM ,Witness #3 (the night supervisor) was asked to verify that her typed statement was accurate. Witness #3 verified the statement was accurate and confirmed it was written on 8/25/2021. Witness #3 was asked if she instructed RN #3 to obtain vital signs and do an assessment on Patient #1 after being told of the alleged abuse by RN #3 and Witness #3 stated, "Yes..."
Witness #3 was asked if she reassigned Named RN #3 after going into the patient's room and being told by Witness #1 and #2 of the alleged abuse. Witness #3 stated "No, I instructed Named RN #3 not to go into the room unless someone was with him and to keep the door open..."

Review of the written statement from the DQR dated 8/25/2020 revealed, "While investigating the situation surrounding Named Patient #1 fall in [named room number], I [DQR] spoke with patient [Patient #1]" The DQR documented, "...When I spoke with [Patient #1] today, [Patient #1] was able to describe the situation. [Patient #1] said that he walked to the bathroom because his pull up was wet. When trying to reach for the light, he fell from the toilet. When the nurse, [RN #3] entered the room, Patient #1 stated [RN #3] yelled to get up. [Patient #1] said he tried but was unable to get up. [RN #3] was nudging Patient #1 with his foot as RN #3 was telling Patient #1 to get up, which Patient #1 said that hurt. When I asked for clarification, [Patient #1] showed me that RN #3 was pushing on him with his foot. [Patient #1] said [RN #3] did not kick him, but again repeated to RN #3 that it hurt..."

During an interview on 9/28/2021 beginning at 11:52 AM, the DQR was asked to verify if her typed statement was accurate. The DQR verified the statement was accurate and confirmed it was written on 8/25/2020.

During a telephone interview on 9/28/2021 at 2:25 PM, RN #3 was asked to verify his written telephone statement given to the HRD and RN #3 stated, "...Stop right there...I've already been to court over this and it was dismissed. I have a lawyer and if you need anything you can contact my lawyer and you can contact the Board of Nursing to get his name...I have no comment do you understand Comprende..."

The hospital failed to ensure that hospital administration and supervisors followed hospital policy to keep patients safe. Hospital staff reported the abuse immediately to supervisors. The hospital failed to follow the abuse prevention policy and ensure all necessary steps were taken to keep patients safe and free from abuse. The night Supervisor failed to follow the abuse policy and immediately report to the Chief Executive Officer, Chief Nursing Officer and/or the Administrative personnel on call the witnessed abuse of Patient #1. After the report of the witnessed abuse by RN #3 to Patient #1, RN #3 was asked to perform an assessment of the patient by the supervisor. The hospital identified the incident as an isolated and no re-education of abuse or other abuse interventions were developed or implemented by the hospital to ensure all patients remained free from all forms of abuse.

4. Patient #2 was a 68 year old admitted to the hospital on 9/16/2021 for rehabilitation with diagnoses including Myopathy following COVID-19 Pneumonia.
Patient #2 was assessed to be a high risk for falls. A bed alarm was activated for Patient #2.

Review of the staff's rounding notes dated 9/25/2021 for Patient #2 revealed the last time the patient was rounded on and checked for any needs was at 4:04 PM.

At 9:52 PM, the Medication Administration Report revealed Patient #2 received medication.

There was no documentation Patient #2 was seen or rounded on between 4:04 PM and 9:52 PM. (total of 5 hours and 48 minutes)

At 10:06 PM Patient #2's vital signs were taken. No other assessments of patient needs were identified at this time.

On 9/26/2021 at 4:50 AM, a staff member went into Patient #2's and found the patient deceased on the floor. The patient's bed alarm was not activated or alarming.

There was no documentation Patient #2 was seen or rounded on between 10:06 PM on 9/25/2021 and 4:50 AM on 9/26/2021. (total of 6 hours and 44 minutes)

During an interview on 10/6/2021 at 9:30 AM the DQR confirmed patient rounding was not done every 2 hours per protocol. The DQR confirmed the Agency Technician responsible to check on Patient #2 assigned had been found asleep during her shift on two (2) separate occasions and no interventions had been implemented each time the staff had been found asleep. The DQR stated communication was not adequate that night.

During an interview on 10/6/2021 at 2:58 PM the Chief Nursing Officer (CNO) was asked who was responsible to make sure patients' bed alarms were turned on and the CNO stated, "The last person who got the patient up should have reactivated it..."
The CNO was asked if she felt there had been non compliance with the bed alarms prior to this incident and the CNO stated, " yes" and verified there was no documentation of action plans for the return demonstration of knowledge of bed alarms.

During an interview on 10/7/2021 at 7:15 AM, in the conference room RN #1 was asked how Patient #2's bed alarm got turned off and why was it turned off and RN
#1 stated, "...I don't know how the bed alarms got turned off..." RN #1 was asked if Patient #2 was a fall Risk and RN #1 did not give an answer.

During an interview on 10/7/2021 at 8:06 AM the Night Supervisor was asked about the incident that happened on 9/25/2021 on the night shift with Patient #2 and the Night Supervisor stated, "...[Patient #2] was lying in the floor...on the left side with a pool of blood...he had no pulse and was not breathing...it was 4:50 AM [9/26/2021]...When [named Emergency Medical Services] was here Patient #2 was dead..."

During an interview on 10/12/2021 beginning at 2:35 PM, the CNO and DQR, the DQR confirmed Patient #2's bed alarm was not activated. The DQR stated a root cause analysis was done and several things were discovered such as a lack of communication and adequate training for new hires. The DQR stated bed alarm use needed additional training with return demonstrations. The CNO stated "staffing was an issue..."

There was no documentation of new interventions developed and implemented to prevent fatal falls for other patients in the hospital.

5. Patient #3 was a 79 year old admitted to the hospital on 8/27/2021 for rehabilitation with diagnoses including Toxic Myopathy associated with Streptococcal Pneumonia.

Patient #3 was assessed as a high fall risk on 8/30/2021 at 9:33 AM.

Patient #3 had an unwitnessed fall on 8/30/2021 and was found on the floor at 11:15 PM. Patient #3 had sustained a head injury.

The physician was notified with no new orders identified in the medical record.

No physician progress notes were identified related to Patient #3's injuries post fall.

Review of Patient #3's post fall assessment on 8/30/2021 at 11:52 PM revealed Patient #3 had a major fall injury. The activity at the time of the fall was unknown. Patient #3 was unsure where she was going at the time and did not use the call light for assistance. Patient #3 was assessed and an abnormality was found to the head which was documented as, "...Round, edematous area noted to left forehead present on assessment that is 4.5 cm [centimeters]...Denies any pain at site on assessment..." An assessment of Patient #3's lower extremities revealed the right and left lower extremities moved against gravity, the tone was normal and sensation was intact. A neurological assessment was completed on 8/30/2021 at 11:15 PM which was documented as neurologically intact. There were no other assessments documented or completed on Patient
#3.

Review of Patient #3's Medication Administration Record (MAR) revealed acetaminophen 650 milligrams (mg) was administered on 8/31/2021 at 1:36 AM for patient complaints of lower leg pain with a pain score of 8 on a scale of 1 - 10 with 10 being the most severe.

There was no documentation the physician was notified about Patient #3's lower leg pain or pain level.

On 8/31/2021 at 7:31 AM Patient #3 was administered acetaminophen 650 mg for lower leg pain with a pain score of 10.

There was no other documentation of the assessment of the patient's pain.

A nursing progress note dated 8/31/2021 at 10:17 AM revealed, Patient #3 complained of pain at the left hip. Patient #3 stated the pain was 10/10 (highest level of pain on the pain scale). Patient #3 revealed she was unable to straighten or bear any weight. Patient #3 also had a left scalp hematoma. The nursing supervisor was asked to call the physician and report Patient #3's left hip pain and change in mobility.

Patient #3 complained of pain 2 times after the fall. The Physician was not contacted until 2 hours and 45 minutes after the second complaint of pain.

On 8/31/2021 at 8:11 AM, Patient #3 was transferred out to the acute care hospital per physician's order and was admitted with left hip fracture and a left frontal hematoma..

During an interview on 10/12/2021 beginning at 2:35 PM, the CNO and DQR stated that Patient #3 was not wearing grip socks as needed and confirmed the bed alarm was not activated. The CNO and DQR confirmed Patient #3 had a left hip fracture and underwent surgery on 8/31/21 for femoral head repair after getting the report from the acute care hospital. The CNO confirmed re-assessment education was needed.

There was no documentation of new interventions developed and implemented following the fall of Patient #3.

6. Patient #4 was 74 years old and admitted to the hospital on 7/31/2021 for rehabilitation with diagnoses including Critical Illness Myopathy.

Patient #4 was assessed as a high fall risk on 7/31/2021 with a Morse Fall Risk Score of 50.

On 8/3/2021 Patient #4 was re-assessed with a Morse Fall Risk Score of 40. According to the Fall Prevention Policy Patient #4 was a moderate fall risk with a score of 40.

Patient #4 was a moderate fall risk according to the policy, however, there were no interventions put in place to prevent falls for Patient #4.

Review of a Physical Therapy (PT) Daily Document dated 8/6/2021 at 1:00 PM revealed, "...Pt requires prolonged rest breaks due to fatigue...Assessment...Impairments/Limitations-PT: Impaired gait, bed mobility deficits, Impaired activity tolerance. Range of motion deficits, strength deficits, Transfer deficits, Wheelchair mobility deficits..."
This PT session began at 1:00 PM and ended at 2:30 PM and Patient #4 was taken back to her room and left unattended in the wheelchair.

On 8/3/2021 at 2:40 PM Patient #4 was found on the floor in front of her wheelchair. This was ten (10) minutes after being left in the wheelchair in her room unattended.

Review of the hospital investigation revealed Patient #4 stated she got up from her wheelchair to plug in her cell phone and fell and hit her head.

The hospital did not follow their Fall Prevention Policy when Therapy notes were not taken into consideration when Patient #4 was assessed for a fall risk.

During an interview on 10/12/2021 beginning at 2:35 PM, the CNO and DQR were asked about the use of a wheelchair alarm for patients with a Morse Fall score of 40 and the CNO stated there was a seat alarm decision tree that the staff used as a guide and the decision tree documented patients with a fall risk score of greater than 45 require a seat alarm and verified if the fall risk was less than 45 and the patients have any of the following such as communication deficit, incontinence, altered mental status or impulsivity then they would require a seat alarm. The CNO confirmed this practice (Seat Alarm Decision Tree) is not documented in the Fall Prevention Policy, it is just what they do in this hospital.

There was no documentation of new interventions developed and implemented following the fall of Patient #4.

Based on document review, medical record review and interview, nursing services failed to ensure staff were capable of following assignments and monitoring patients for in order to meet all patients needs for 1 of 1 (Rehabilitation Nursing Technician (RNT #1) RNTs observed sleeping while on duty.

The findings include:

During an interview in the conference room on 10/6/2021 with the Director of Quality and Risk (DQR) and the Chief Nursing Officer (CNO), the DQR confirmed RNT #1 was found sleeping by the night Nursing Supervisor. The DQR confirmed staffing was short and communication was not adequate that night. The CNO stated, "I assume it was around 3:00 AM, my understanding the call lights on the hall RNT #1 was assigned to were going off and another Tech found her [RNT #1 asleep] in three chairs and a blanket over her in the hall.

During an interview on 10/7/2021 at 7:15 AM, Registered Nurse (RN) #4 was asked to describe what happened on the 7:00 PM to 7:00 AM shift on 8/25/2020 and RN
#4 stated, "...RNT #1 also had patients on two different halls. So when we first thought she was sleeping I was informed by another Tech...that RNT #1 was asleep...So a little later on [RN #2] told [Named Night Supervisor] that RNT #1 had been sleeping... [Named Night Supervisor] went down and talked to RNT #1, this was a little after midnight..."

During an interview on 10/7/2021 at 8:06 AM, the Night Supervisor was asked about the agency RNT #1 being found asleep and the Night Supervisor stated, "...Multiple call lights were going off and RNT #2 got up and went down there and found RNT #1 sleeping and...woke her up and told RNT #1...to start answering the call lights. [Named RNT #2] told [Named RN #2] about it and [Named RN #2] was going to come tell me that they found [RNT #1] sleeping. [Named RN #2] said [RNT #1] is back laying down you could see her feet. [RNT #1] was lying in 3 chairs and in such a deep sleep...it took me 3 times calling her name before she answered me. I took 2 of the chairs and put them in a different area and told [RNT #1] we do not sleep while we are working. I did not call the Administrator on Call [AOC] at this time because they always fuss if we call them and wake them up. They [Administration] tell us if we find them sleeping to send them home but because [RNT #1] was contract and I knew the facility was going to have to pay her anyway. I texted the AOC on call instead of calling..."
Refer to A - 144 and A - 145.