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Based on document review and interview, the governing body failed to ensure doctors responsible for patient care examined 2 of 10 (P3 and P8) patients involved in accidents/falls as per hospital policy.

Findings include:

1. The policy titled Maintaining Patient Records and Documentation, Subject: Completion of (hospital) Confidential Incident Report/Confidential Employee Incident Report - Patients, Visitors, and Staff, Revised 7/2010, indicated the following:
i. Policy: Guidelines are established to ensure patient safety, immediate treatment if necessary and proper documentation of any incident involving (hospital) patients/visitors or staff.
ii. General Guidelines: 3. Patients involved in accidents should be examined by the attending physician or his/her designee.

2. Review of hospital Incident Reports (IR) and Patient Fall Investigation Reports (FIR) from 4/1/18 to 7/31/18 indicated patients P3 and P8 had a documented fall on date(s) and time(s) indicated:
A. P3: On 5/27/18 at 2215 hours. Falls: Unassisted Fall/Reported fall, found in bed. FIR dated 5/27/18, indicated the following: Potential contributing medications: Narcotics/muscle relaxers. Action Plans: Pharmacist to review meds. MD (physician) to assess.
B. P8: On 4/2/18 at 1520 hours. FIR dated 4/2/18, indicated the following: Potential contributing medications: Sedative/hypnotics. Action Plans: Pharmacist to review meds. MD to assess.

3. Review of medical records (MR) indicated the following:
A. Patient P3 had a fall "Occurrence" documented as 5/28/18 at 12:12 am. The MR lacked documentation of MD examination/assessment following the fall dated 5/27/18 per IR or 5/28/18 per the MR "Occurrence".
B. Patient P8 had a fall "Occurrence" documented as 4/2/18 at 7:57 PM. The MR lacked documentation of MD examination/assessment following the occurrence/IR dated 4/2/18.

4. A. On 8/1/18, between approximately 10:30 AM and 12:30 AM, A6, Nurse Educator, indicated that Action Plans of the FIR following an incident should be implemented. A6 verified the MR of P3 lacked documentation of physician examination/assessment following the fall/accident.
B. On 8/2/18, between approximately 9:30 AM and 1:45 PM, A6 and A7, Quality Manager, verified that the MR of patient P8 lacked documentation of physician examination/assessment following the fall 4/2/18.

Based on document review, observation and interview, the nursing supervisor failed to supervise and evaluate care for 10 of 10 (P1, P2, P3, P4, P5, P6, P7, P8, P9 and P10) patients in medical record review and 2 of 5 observed patients (PD and PE) to assure care was provided in accordance with hospital policies for Falls Prevention, Adverse Drug Reaction Report and Patient Records Documentation and failed to ensure Action Plans were implemented following fall related incidents for the 10 patients (P1, P2, P3, P4, P5, P6, P7, P8, P9 and P10).

Findings include:

1. Review of hospital policies indicated the following:
A. Policy titled Safety Emergencies, Subject: Falls Prevention Program, Revised 3/2018:
i. 3. Appropriate safety measure are initiated, according to patient risk factor scores. Level I, 0-39. Level II, 40-79. Level III, 80 or greater.
ii. 4. All patients including those with scores up to 39 are considered a Falls Risk Level I and will have routine safety measure initiated on admission.
a. Assess ability to use nurse call
b. Call bell within reach
c. Side rails up x 2 when in bed
d. Transfer belt
e. Non-slip footwear
f. Night light
g. Patient safety education
h. Assess elimination needs every 2 hours
iii. 5. All patients with scores between 40-79 are considered Falls Risk Level II and will have the following safety measures initiated.
Must have:
a. All Level I safety measures.
b. Supervision while in the bathroom
c. Yellow wrist band
d. Yellow dot on Patient door tag
e. Bed check/chair check
Consider:
a. Need for room assignment near nurse's station
b. Need for low bed
c. Need for enclosure bed
d. Consider need for self-release alarming seat belt
iv. 6. All patients with a score of 80 or greater are considered Falls Risk Level III and will have the following safety measures initiated.
Must have:
a. All level I safety measures
b. Continuous observation while out of bed
c. Supervised elimination and hygiene
d. Yellow-stripe arm band replaced solid yellow arm band
e. Yellow-strip dot replaces solid yellow dot on door tag
f. Chair check
g. Bed check
h. Low bed
Consider:
a. Need for room assignment near nurse's station
b. Wanderguard
c. Enclosure bed, plus bed check if indicated
d. Restraints
e. Sitter
v. 10. If a patient experiences a fall: b. The patient will be assessed for injury.
B. Policy titled Administration of Medication/Blood, Subject: Adverse Drug Reaction Report, Reviewed 03/2017:
i. 5. Reactions to be reported include the following:
a. Idiosyncrasies (uncharacteristic response of a patient to a drug, occurring on administration of a drug in normal doses)
b. Drug to drug interactions
f. Drug intolerance
g. Side effect (an adverse pharmacologic effect of a drug unassociated with the therapeutic purpose for which the drug is given. Those reactions requiring corrective measures should be reported)
ii. 7. The pharmacy is notified of an adverse drug reaction by calling the "ADR" link. The nurse calling simply needs to answer the questions as they are asked.
C. Policy titled Maintaining Patient Records and Documentation, Subject: Completion of (hospital) Confidential Incident Report/Confidential Employee Incident Report - Patients, Visitors, and Staff, Revised 7/2010:
i. Policy: Guidelines are established to ensure patient safety, immediate treatment if necessary and proper documentation of any incident involving (hospital) patients/visitors or staff.
ii. General Guidelines: 1. A (hospital) Confidential Incident Report form is used to report any accident or unusual occurrence involving a patient or visitor. 3. Patients involved in accidents should be examined by the attending physician or his/her designee. 5. The incident, if patient-related, is to documented in the Nursing Notes if pertinent. Procedure: 2. Notify physician of patient falls or other incidents. All patients who fall are to have a Falls Assessment done by the Safety Officer with appropriate follow-up.
D. Patient Fall Investigation Report form, Updated 9/7/2016: Review of the form indicated that following investigation of a fall, Action Plans that were indicated by check marks were to be implemented.

2. Review of hospital Incident Reports (IR) and Patient Fall Investigation Reports (FIR) from 4/1/18 to 7/31/18 indicated the following patients (P1, P2, P3, P4, P5, P6, P7, P8, P9 and P10) had a documented fall on date(s) and time(s) indicated:
A. P1: On 4/22/18 at 0900 hours. Description: Pt (patient) was found on his/her knees next to his/her W.C. (wheelchair) with locks disengaged. Pt stated that he/she slid to the floor trying to reach TV (television) to turn channels. Call light was in reach but pt had not called. No injury noted. FIR, dated 4/23/18, indicated the following: Potential contributing medications: Psychotropics. Action Plans: Pharmacist to review meds (medications).
B. P2:
i. On 5/26/18 at 2255 hours. Description: Patient bed alarm sounded. Upon entering room, patient found on mat next to bed. Pt on knees facing bed. Patient was confused, as is baseline... FIR dated 5/27/18, indicated the following: Action Plans: Pharmacist to review meds.
ii On 5/27/18 at 2200 hours. Description: Staff responding to bed alarm found pt sitting on floor mat next to the lowboy bed. SCDs (sequential compression device) still attached to LEs (lower extremities). FIR dated 5/27/18, indicated the following: What patient was doing at time of fall: Going to bathroom. Potential contributing medications: Diuretics. Action Plans: Pharmacist to review meds.
iii. On 6/1/18 at 0800 hours. Description: CNA (Certified Nursing Assistant) was assisting patient to bathroom from wheelchair to toilet, and patient's legs gave out. FIR dated 6/1/18, indicated the following: What patient was doing at time of fall: Going to bathroom. Potential contributing medications: Narcotics. Antihypertensives. Diuretics. Action Plans: Pharmacist to review meds.
iv. On 6/2/18 at 2220 hours. Description: Pt called out to request transfer OOB (out of bed). Before staff could page the alarm sounded and staff went straight to the room. Pt was found on door side of room, sitting on bottom in upright position. FIR dated 6/2/18, indicated the following: What patient was doing at time of fall: Getting out of bed. Potential contributing medications: Sedative/hypnotics. Narcotics. Action Plans: Pharmacist to review meds. Enclosure bed.
C. P3: On 5/27/18 at 2215 hours. Falls: Unassisted Fall/Reported fall, found in bed. FIR dated 5/27/18, indicated the following: Potential contributing medications: Narcotics/muscle relaxers. Action Plans: Pharmacist to review meds. MD (physician) to assess.
D. P4: On 6/5/18 at 1645 hours. Description: Pt was sitting at the west nurse's station in wheelchair, as walked away from desk Pt stood up and turned. Elbow hit door in hallway and pt lost balance and fell. Falls: Unattended. Activities: Up in chair/wheelchair. FIR dated 6/5/18, indicated the following: Potential contributing medications: Sedatives/hypnotics. Action Plans: Timed voids. Pharmacist to review meds. Bed and chair alarm. Alarming seatbelt. Alarming roll-belt in bed.
E. P5: On 6/6/18 at 1220 hours. FIR dated 6/6/18, indicated the following: Action Plans: Pharmacist to review meds. Remove clutter.
F. P6: On 6/15/18 at 0330 AM. FIR dated 6/15/18, indicated the following: Potential contributing medications: Sedatives/hypnotics. Psychotropics. Action Plans: Pharmacist to review meds.
G. P7: On 6/25/18 at 0215 hours. FIR dated 6/25/18, indicated the following: Action Plans: Pharmacist to review meds.
H. P8: On 4/2/18 at 1520 hours. FIR dated 4/2/18, indicated the following: Potential contributing medications: Sedative/hypnotics. Action Plans: Pharmacist to review meds. MD to assess.
I. P9: On 4/6/18 at 1200 hours. FIR dated 4/6/18, indicated the following: Potential contributing medications: Narcotics. Action Plans: Pharmacist to review meds.
J. P10: On 4/9/18 at 2:00 PM. FIR dated 4/9/18, indicated the following: Action Plans: Pharmacist to review meds.

3. Review of medical records (MR) indicated the following:
A. Patient P1 had a fall occurrence documented as 4/22/18 at 8:52 AM. The MR lacked documentation of nursing notifying pharmacy for review of medications following the fall on 4/22/18.
B. Patient P2:
i. Had a fall "Occurrence" documented as 5/27/18 at 4:40 AM which indicated staff responded to a bed alarm and patient was found on the floor beside the bed on the fall mat. Patient was positioned on knees facing bed. The MR lacked documentation of an Occurrence on 5/26/18. The MR Nursing Notes lacked documentation of a patient fall on 5/26/18 and lacked documentation of a fall on the morning/day of 5/27/18 between 0001 hours and 22:30 hours. The MR indicated that on 5/27/18 at 22:30 hours a FRA (Falls Risk Assessment) was completed with the Reason for Assessment indicated as "Fall", however, the MR Nursing Notes lacked documentation of a fall at or near that time and date. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications following the fall dated 5/26/18 per IR or 5/27/18 per the MR "Occurrence".
ii. Had a fall "Occurrence" documented as 5/28/18 at 12:37 AM, which indicated staff found pt sitting on floormat next to her/his lowboy bed when responding to bed alarm at 2205 hours. Pts SCDs were still attached to her/his legs. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications following the fall dated 5/27/18 per IR or 5/28/18 per the MR "Occurrence".
iii. Had a fall "Occurrence" documented as 6/1/18 at 08:40 AM. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications following the fall/IR/Occurrence dated 6/1/18.
iv. Had a fall "Occurrence" documented as 6/2/18 at 11:32 PM. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications following the fall/IR/Occurrence dated 6/2/18. The MR indicated the physician ordered an enclosure bed on 6/2/18 at 2306 hours. The MR Hourly Assessment Restraint Flow Sheet indicated the orders were not implemented until 6/4/18.
C. Patient P3 had a fall "Occurrence" documented as 5/28/18 at 12:12 am. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications.
D. Patient P4 had a fall "Occurrence" documented as 6/5/18 at 5:22 PM. The MR indicated the patient was a falls risk level 3 at all times during hospitalization. The MR lacked documentation of continuous observation at all times while out of bed. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications, bed and chair alarm in place, alarming seatbelt or alarming roll-belt in bed following the fall/IR/Occurrence dated 6/5/18.
E. Patient P5 had a fall "Occurrence" documented as 6/6/18 at 12:46 PM. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications or removal of clutter.
F. Patient P6 had a fall "Occurrence" documented as 6/15/18 at 7:16 AM. The MR Nursing Notes lacked documentation of a patient fall on 6/15/18. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications.
G. Patient P7 had a fall "Occurrence" documented as 6/25/18 at 6:20 AM. The MR Nursing Notes lacked documentation of a patient fall on 6/25/18. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications.
H. Patient P8 had a fall "Occurrence" documented as 4/2/18 at 7:57 PM. The MR Nursing Notes lacked documentation of a patient fall on 4/2/18. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications.
I. Patient P9 had a fall "Occurrence" documented as 4/6/18 at 2:40 PM. The MR Nursing Notes lacked documentation of a patient fall on 4/6/18. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications.
J. Patient P10 had a fall "Occurrence" documented as 4/9/18 at 5:25 PM. The MR lacked documentation of nursing notifying pharmacy for pharmacist review of medications.

4. On 8/2/18 between approximately 2:45 PM and 3:00 PM, during tour of the inpatient unit, in the presence of A6, nurse educator, the following was observed:
A. In a patient room, the patient, PD, was designated as a fall risk level 1 on whiteboard and a fall risk level 2 according to the yellow dot outside the door and the yellow wrist band on the patient. The patient was out of bed sitting in a chair at bedside. The chair was equipped with an alarm, however, the alarm was not engaged/was off.
B. In a patient room, the patient, PE, was designated as a fall risk level 2 according to the yellow dot outside the door, the white board and the yellow wrist band. The patient was lying in bed. The bed alarm was disengaged/was off.

5. Interviews;
A. On 8/1/18, between approximately 10:30 AM and 12:30 AM, A6, Nurse Educator, indicated that Action Plans of the FIR following an incident should be implemented. A6 verified the MR of P1, P2 and P3 lacked documentation of nursing notifying pharmacy for pharmacist review of medications.
B. On 8/2/18, between approximately 9:30 AM and 1:45 PM, A6 and A7, Quality Manager, verified that the hospital policy indicated falls are to be documented in the MR nursing notes and that Nursing Note documentation under "Safety, Falls Risk Assessment" is documentation of FRA following a fall indicating the change in fall risk level and is not nursing documentation of a fall. A6 and A7 also verified that the MRs of patients P4, P5, P6, P7, P8, P9 and P10 lacked documentation of nursing notifying pharmacy for pharmacist review of medications and that the MRs of patients P6, P7, P8 and P9 lacked nursing note documentation of falls.