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Based on observation, interview, record review and policy review the facility failed to:
- Ensure nursing staff monitored and observed one of one discharged patient (#18) reviewed after she had fallen and hit her head. (Refer to A-0395)
- Ensure nursing staff followed facility policy for notification of the physician in a timely manner, for two patients (#20 and #21) of three current patients reviewed who had fallen. (Refer to A-0395).
- Ensure nursing staff updated the care plan to identify that the patient had fallen and to prevent further falls and injuries for two current patients (#10 and #20) of three current patients reviewed who had fallen and one discharged patient (#18) of one discharged patient reviewed. (Refer to A-0395)
These failures had the potential to place all patients admitted to the facility at risk for their health and safety related to falls. The facility reported 39 patient falls over the past six months. Seven of these resulted in patient injury. The facility census was 30

These failures created an unsafe environment and had the potential to place all patients admitted to the facility at risk for their safety. The facility census was 30.

The severity and cumulative effect of these systemic practices resulted in an overall non-compliance with 42 CFR 482.23 Condition of Participation: Nursing Services and resulted in a condition of Immediate Jeopardy (IJ).

On 11/03/17 the facility had provided an immediate action plan sufficient to remove the IJ when the facility implemented the following actions:
- Attending physicians were to be called immediately on all patients will falls.
- The attending physician will notify the facility if he can be present within 30 minutes, if he is unable to physically be present to assess the patient within 30 minutes the physician will determine if he gives an order to send the fall patient to the Emergency Room.
- The Governing Board met and sanctioned that the Registered Nurses, (RN), Licensed Practical Nurses, (LPN), Certified Nursing Assistants, (CNA's) Environmental, (EVS) staff, Dietary staff, Security, Pharmacy staff and Plant Operations will receive training on fall prevention and interventions prior to their next scheduled shift to work.
- On 10/19/17 the Governing Board sanctioned immediate 100% house wide fall risk assessment review to be conducted with application of appropriate fall prevention measures.
- Prior to attending physician's next shift or visit to see patients, they received education from the Physician Advisor regarding the updated bylaws with 30 minute response time.
- For each fall occurrence, the RN House Supervisor, Nurse Manager or Chief Clinical Officer will respond to the fall event and conduct a bedside assessment and review that interventions are in place and that care plan is updated and is appropriate.
- Rapid Response Team calls for all witnessed or unwitnessed fall patients were initiated. Fall risk scores were added to the end of shift report to identify high risk patients and to communicate from RN Supervisor to RN Supervisor of the high risk fall patients in house.
- Training to nursing staff included that all falls require a neurological assessment and vitals documentation as part of the post fall assessment requirement.
- Facility and Medical Staff expectations of attending physicians are as follows:
- Nursing staff to immediately notify physician of all falls;
- Expectations also include having the attending or covering physician respond to assess the patient face to face within 30 minutes of being notified; and
- Provide an on call list for the physicians for the next week.
- System changes were a policy addendum to Fall Prevention Policy rational is to ensure that the neurological status of patients are being assessed for any changes post fall. The addendum process stated that any patient falls will be evaluated with neurological checks every 15 minutes for one hour, every 30 minutes for two hours, every one hour for four hours and then every four hours for a total of 24 hours. If any changes in the patient's neurological status, the physician will be notified immediately.
- Medical Staff Bylaws were made to 2.6.16 participate in consultation and/or on-call panels as permitted and required by the rules, this includes but is not limited to a requirement that an attending physician is listed on the hospital's emergency on-call roster for their patient, to enable the facility to immediately contact the attending physician in situations necessitating an immediate physician response, and when notified, as the attending physician, he or she agrees to provide emergency medical services in person at the facility within a response time of thirty minutes or less.
- Fall mock drills were initiated every shift for a period of two weeks. Once 100# compliance is achieved following two weeks, fall mock drills will reduce to three times per week. Once 100# compliant with fall mock drills at three times per week, then mock drills de-escalate to twice per week.

Based on observation, interview, record review and policy review the facility failed to:
- Ensure nursing staff monitored and observed one discharged patient (#18) of one discharged patient reviewed after she had fallen and hit her head.
- Ensure nursing staff followed facility policy for notification of the physician and family, in a timely manner, for two patients (#20 and #21) of three current patients reviewed who had fallen.
- Ensure nursing staff updated the care plan to identify that the patient had fallen and to prevent further falls and injuries for two current patients (#10 and #20) of three current patients reviewed who had fallen and one discharged patient (#18) of one discharged patient reviewed.
- Ensure nursing staff completed a skin assessment that identified and treated skin abrasions for one current patient
(#19) of one current patient reviewed who had unidentified skin abrasions.
These failures had the potential to place all patients admitted to the facility at risk for their health and safety related to falls and lack of skin assessments. The facility reported 39 patient falls over the past six months. Seven of these resulted in patient injury. The facility census was 30.

Findings Included:

1. Record review of the facility's policy titled, "Falls Prevention," dated 06/2017, showed the following:
- Patients are screened for risk of falls on admission, weekly and with any significant change in condition;
- A fall is defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface;
- A score of 10 or greater equals at risk. Those patients identified as being "at risk" for falls will have additional interventions added to their plan of care in an effort to prevent falls.
- In the event that a patient fall occurs, regardless of the score of the initial fall risk screen, he/she will be automatically considered at risk for falls, additional interventions will be considered, and the Care Plan revised to reflect increased risk.

2. Record review of the facility policy titled, "Assessment/Re-Assessment Interdisciplinary Patient," dated 06/2017 showed direction for the notification responsibilities when an assessment reveals a Change or Suspected Change in Condition was for staff assigned to the patient or supervising the care of the patient is responsible for notification and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response.

3. Record review of the facility document titled, "List of Events Report," showed the facility had 39 patient falls between 04/01/17 and 10/16/17. Seven falls were with patient injury and thirty two without injury. Twenty eight (28) out of the 39 falls were unwitnessed falls.

4. During an interview on 10/18/17 at 09:30 AM, Staff S, Registered Nurse, (RN) stated that Patient #18 had fallen on 8/28/17 at approximately 7:30 AM. She heard a loud noise, went to the room and found patient #18 lying on her back on the floor. The Tele-Medicine (Tele-Med, remote diagnosis and treatment of patients by means of telecommunications technology) physician was notified and the electronic screen was brought into the room for the doctor to view the patient on the screen for an assessment. Staff S stated that the Tele-Med physician ordered to continue to monitor the patient and continue neurological checks (neuro checks, used to assess an individuals neurological functions and level of consciousness).

Record review of Patient #18's nursing assessment dated 08/25/17 showed the following:
- Patient #18 had a fall risk score of four at the time of her fall.
- At 11:46 AM a telephone order (T.O.) was received from the primary care physician (PCP) to continue neuro checks every 2 hours.
- Staff S, RN acknowledged the T.O. at 12:56 PM
- The order was initiated at 1:21 PM.
The nursing assessment did not show documentation of the Tele-Med physician order for neuro checks after the patient had fallen. The PCP's telephone order for neuro checks was initiated at 1:21 PM, approximately six hours after the patient had fallen.

During a telephone interview on 10/18/17 at 2:30 PM, Staff U, Tele-Medicine doctor stated that he gave a verbal order to continue neuro checks. He stated that he wasn't sure how to enter this as an actual order in the electronic medical record (EMR). Staff U stated that through his conversation with Staff S, RN he felt he was defining a four hour plan until he contacted the PCP and his orders would take precedence at that time. Staff U stated that he then called the PCP.

The facility staff failed to follow physician orders to perform neurological examinations for Patient #18 following a fall when the Tele-Medicine physician had given a verbal order for them to be performed. The facility also failed to update the fall risk assessment and the care plan following the fall. The T.O. from the PCP was received at 11:46 AM, but was not initiated until 1:21 PM. Patient #18 was assessed to have had a decrease in her mental status at 1:22 PM and was transferred to Facility B at 2:11 PM. Patient #18's family was not notified that the patient had fallen.

Record review of Patient #18's medical record from facility B showed that the patient arrived at facility B's Emergency Department (ED) at 3:48 PM. She received a Computerized Tomography (CT, special X-ray tests that produce cross-sectional images of the body) scan that showed a small left parietal scalp hematoma (collection of blood underneath the skin of the scalp usually caused from head trauma). Patient #18 was transferred to facility C for neurological care.

During an interview on 10/16/17 at 8:25 AM, Staff H, RN, House Supervisor stated that if a patient had fallen that the nurse was to immediately assess the patient including obtaining vital signs (heart rate, respirations and blood pressure) notify the physician, and notify the family. If the patient needed physician evaluation then the Tele-Med physician would be called and the Tele-Med machine (monitor) would be brought into the patients' room for visual assessment. Staff H stated that the facility had radiology services on-site but if the patient needed a CT scan that they would have to be transferred to an outside facility that provided those services.

5. Record review of Patient #20's medical record showed the following Change of Condition documentation dated 10/16/17 at 3:15 AM by Staff P, RN:
- Heard patient yelling "help me";
- When entered the room the patient was observed to be kneeling on the floor mat beside the bed;
- Patient stated that the he wanted to get out of his bed;
- Observed skin tear to patient's right great toe;
- Skin tear cleansed with wound wash, xeroform (gauze wound dressing soaked in a mixture of bismuth tribromophenate [medicine] and petroleum jelly) and wrapped with a gauze dressing;
- Family not notified at this time; and
- Will notify Advanced Registered Nurse Practioner (ARNP, a RN who has completed graduate-level educational program) during AM rounds.

During an interview on 10/18/17 at 3:40 PM, Staff P, RN stated that Patient #20 had floor mats on both sides of the bed and a bed alarm. She stated that the bed alarm had not alarmed when the patient got out of bed but it did alarm when she tested it after the patient had fallen. She stated that she didn't like to notify family during the middle of night and that she meant to notify them later in the morning but it "slipped her mind." Staff P, RN, stated that she expected the ARNP around 6:00 AM as that was when he usually made his morning rounds and she had planned on telling him at that time so she didn't enter the notification into the computer system because of this.

Patient #20 fell at approximately 3:15 AM and the Tele-Med physician was not notified and the nurse planned on verbally informing the ARNP when he made his morning rounds. There was no immediate notification to a physician or advanced practice nurse that Patient #20 had fallen out of bed.

6. Record review of Patient #21's medical record showed the following Change of Condition dated 10/04/17 at 4:56 PM by Staff R, RN:
- Patient fall at 12:30 PM;
- Found on floor at the left side of the bed in a sitting position by Respiratory Therapy;
- Patient denied pain;
- Alert and responsive;
- Denied hitting head on any surface;
- Notified physician when here for rounds; and
- Reminded to use call light.

During an interview on 10/18/17 at 11:10 AM, Staff R, RN stated that the physician was to be immediately notified when a patient had fallen. He stated that Patient #21's physician usually made rounds between 12:00 Noon and 2:00 PM and if the patient would have been injured he would have notified the Tele-Med physician.

7. Record review of Patient #10's medical record showed the following Change of Condition dated 10/13/17 at 10:40 AM by Staff I, RN:
- Patient fell while trying to wipe herself;
- Found in the bathroom on the floor;
- Patient complained of right knee, right wrist and lower back pain;
- Physician notified; and
- No documentation of family notified.

During an interview on 10/18/17 at 10:20 AM, Staff I, RN stated that she did not notify Patient #10's family after she had fallen because the patient was alert and oriented and had daughters that came to see her so she would be able to inform them of the fall. She stated she did not update the care plan or the fall risk score after the patient had fallen.

During an interview on 10/17/17 at 11:13 AM, Staff K, RN stated that she had worked the weekend and had been assigned to care for Patient #10 on Sunday 10/15/17. She had heard from the weekend staff that Patient #10 had fallen on Friday (10/13/17). Staff K stated that if you answered yes to the fall history that it would automatically add 10 to the patient's fall score. Staff K stated that she had updated the fall history today which in turn increased the patient's fall risk score.

Record review of Patient #10's medical record on 10/17/17 showed the total fall risk scores from 10/13/17 to 10/15/17 as a score of two with a zero score for the fall history with no update to the care plan of the patient fall. The fall risk score on 10/16/17 was a score of 12 with a zero score for the fall history. The fall history score was not updated until 10/17/18, four days after Patient #10 had fallen.

During an interview on 10/18/17 at 3:50 PM, Staff C, RN, Nurse Manager stated that she was aware of the high number of falls for the past six months. She stated that nursing staff were to notify physicians and family after a patient had fallen and to update the fall risk score, interventions to prevent future falls and to update the care plan.

During an interview on 10/18/17 at 3:04 PM, Staff E, CCO stated that she expected nursing staff to immediately assess a patient who had fallen, notify the physician and nursing supervisor. She stated that she expected an immediate debriefing to discuss what and why the fall or other incident had occurred and if there was patient harm she wanted to be notified.

8. Record review of the facility policy titled, "Assessment/Re-Assessment - Interdisciplinary Patient," dated 06/2017 showed:
- Patients are re-evaluated by a licensed nurse (RN, Licensed Practical Nurse, LPN) at a minimum every 12 hour shift based on level care and patient needs.
- An RN reassessment of the patient shall occur, at a minimum of once every other 12 hour shift;
- An LPN may gather clinical data and make clinical observations in between the RN assessments. The clinical data and clinical observations are reported to the RN for evaluation and determination of needed changes in the patient plan of care; and
- Patient reassessment is based on but not limited to evaluate patient response to care, treatment, and services and to respond to a significant change in status and/or diagnosis or condition.

9. Observation on 10/18/17 of Patient #19's fourth and fifth toes of the left foot revealed two small brown areas the size of a pencil eraser. Patient #19 shared pictures from her phone she had taken on 10/04/17 of these same areas on her fourth and fifth toes of her left foot. The areas were red and the size of a pencil eraser.

During an interview on 10/18/17 at 9:15 AM, Patient #19 stated that on 10/03/17 or 10/04/17 therapy had scraped her foot while pushing her in the wheelchair and caused two small abrasions on her fourth and fifth toes of left foot. She stated that they did not report it to anyone.

During an interview on 10/18/17, with Staff T, Physical Therapy (PT) Rehabilitation Coordinator stated that Patient #19 was in therapy on 10/03/17 and worked with a self-propelling wheelchair. Staff T stated that the patient had her socks on and at the end of their session he returned her to her room and removed her left sock to put compression stocking and heel protector in place. Staff T stated that there were no areas on her toes at that time and she did not mention it to him. Staff T stated that on 10/13/17 when he was performing range of motion (ROM) to lower extremities he noted the light brown areas on her fourth and fifth toes of left foot, but the patient did not mention how this occurred and Staff T assumed nursing was aware.

During an interview on 10/18/17 at 02:30 PM, Staff V, Wound Coordinator stated that she was not aware of the areas on Patient #19's fourth and fifth toes and that they had not been reported to the wound team.

Record review between 10/03/17 through 10/18/17 revealed that there was no documentation of any skin assessments.













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