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Based on record review and interview, the hospital failed to ensure that the Quality Assessment and Performance Improvement Program (QAPI):


I. reviewed, investigated, analyzed causes, and implemented preventative action plans for 12 (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) out of 12 patient falls resulting in patient injury and communicated lessons learned as evidenced by the lack of QAPI discussion in three of three QAPI meeting minutes from 10/16/18 to 01/17/19.


II. ensured nursing staff completed the "Post Fall Analysis Tool (Post Fall Huddle Form)" for nine out of nine falls for 10/18, 16 out of 16 falls for 11/18, nine out of 12 falls for 12/18, and four out of six falls for 01/19.


These failed practices had the likelihood for improvement opportunities not to be identified, analyzed for causes, and the implementation of preventative measures to improve patient outcomes in the area of patient falls.


Findings:


Review of hospital policy titled "Quality Assurance and Performance Improvement (QAPI) Plan, revised 07/05/17" showed, the QAPI program was responsible for monitoring patient care to "identify and resolve any breakdowns that may resolve any breakdowns that may result in suboptimal patient care and safety ...continuously improve and facilitate positive patient outcomes" ...QAPI Committee provided oversight of patient safety activities which included but were not limited to evaluation of fall reductions.


Review of hospital document titled "Critical Incidents, revised 07/17" showed, critical incident report should be completed on "any incident deemed to be inconsistent with the desired operation of the hospital or care of patients" ...Critical incident reports should be completed for events including but not limited to events: not a "natural consequence of the patient's disease" ...result in injury ...require the patient to be transported to the emergency department (ED) ...Director of Quality would be notified of incidents that were serious ...Department Manager, Supervisor or their designee were responsible for completion of incident follow-up within their area of responsibility. Follow-up was required within the electronic Occurrence Reporting System (ORS) within 48 hours of the incident ...Director of Quality was responsible for reviewing each reported incident, conducting "appropriate follow-up" prior to closing the incident ... "detailed investigations may be referenced in the ORS system and filed as an attachment to the incident report" ...Rationale for incident reporting included but was not limited to: record the incident ...document facts ...provide factual documentation for internal investigation ...statistical analysis and improve services.


Review of hospital document titled "Sentinel Event and Root Cause Analysis, revised 07/05/17" showed, sentinel event was a patient safety event "that reached the patient and resulted in death, permanent harm or severe temporary harm" ...A root cause analysis would be performed to determine the occurrence of an adverse sentinel event.


Review of hospital document titled "Patient Fall Analysis Tool (Post Fall Huddle Form), dated 10/16" showed, analysis of a patient's fall was reviewed for the following information:

- Type of fall

- Location of fall

- Activity when patient fell

- Type of fall prevention strategies in place: call light, side rails, proper footwear, and gait belt in use

- Was the patient on Fall Prevention Policy: bed alarm, was it activated, if patient in a wheelchair was the seatbelt on, and if there was a restraint utilized was it used correctly

- Description of the event and what could have been done differently to prevent the event



Review of hospital document titled "Fall Trends, undated" showed the following:

- 06/18 - Nine falls, two injuries and a fall rate of 8.30

- 07/18 - 11 falls, one injury and a fall rate of 9.30

- 08/18 - Eight falls, two injuries and a fall rate of 7.00

- 09/18 - 14 falls, three injuries and a fall rate 12.2

- 10/18 - Nine falls, three injuries and a fall rate of 7.6

- 11/18 - 16 falls, 10 injuries and a fall rate of 13.7

- 12/18 - 12 falls, four injuries and a fall rate of 9.8


Review of hospital documents titled "Fall Committee Meeting" minutes from 06/18 to 01/19 showed no evidence of the following:

- 10/18 - "Patient Fall Analysis Tool" for all nine falls reported in ORS. The minutes failed to show evidence of discussion related to no post fall huddle forms for the month of October and a committee member from nursing expressing "concerns with charge nurses not completing the post fall forms correctly or at all". There was no evidence that the committee implemented an action plan to improve compliance by staff and reduce the risk to patient safety. There was no evidence of discussion regarding Patient #1 and 5 who were found on floor with bleeding head wounds, and Patient #2 who struck his right shoulder on the sink or wall while performing grooming activities, including the investigation and follow-up to determine the outcome of the patient's injuries and whether there were process failures in relation to the fall prevention program.


- 11/18 - "Patient Fall Analysis Tool" for all 16 falls reported in ORS. The minutes showed "there has been a substantial decrease in post fall huddles completed, no post fall huddles were completed in October". The meeting minutes failed to provide evidence the committee discussed no post fall huddles were completed for November and implemented plan to improve performance. There was no evidence of discussion regarding Patient # 7 who was noted to have a left forehead hematoma and lateral rotation to the left leg, which included investigation and follow-up to determine the outcome of the patient's injuries and whether there were process failures in relation to the fall prevention program.


- 12/18 - "Patient Fall Analysis Tool" for nine of the 12 falls reported in ORS.


- 01/19 - "Patient Fall Analysis Tool" for four of the reported six reported falls in the meeting minutes for 01/17/19. Staff C reported he/she was still not receiving the "Post Fall Huddle Forms". The minutes failed to show evidence the committee discussed the continued non-compliance by staff to complete the post fall huddle forms and action by the committee to implement a plan to improve performance to reduce the risk to patient safety related to falls.



Review of incident reports from 06/01/18 through 01/29/19 showed the following:


- On 01/21/19, Patient #9 found on floor after reaching for something, slid off rolling walker, fell, and hurt his/her right hand. Chair alarm was not activated and call light not placed within reach. Follow-up showed patient was left in room by therapy staff in a rolling walker that had no locking mechanism, did not transfer patient to bed or chair or call for nursing staff prior to leaving patient unattended in unlocked walker. Severity level was noted as level two "minor harm/damage". There was no evidence from the investigation follow-up was completed to determine the outcome of the patient's injuries.


- On 12/12/18, Patient #11 was taken outside by staff at 10:30 am, to smoke and was found on the ground after falling out of their wheelchair while unattended. The investigation failed to identify the length of time the patient was outside unattended by staff prior to the fall, fall risk level, and preventions implemented at the time of the fall. Severity level was noted as a level three "permanent harm/damage". There was no evidence from the investigation follow-up was completed to determine the outcome of the patient's injuries. There was no evidence from review of the investigation it was determined there were no process failures in relation to the fall prevention program prior to the incident being closed.


- On 12/13/18, Patient #10 was found lying in the floor of the bathroom on his/her left side, noted to have non slip socks on. Nurse noted bed alarm had not been activated. Outcome was noted "bed alarm not in use, assisted to bed, alarm activated." There was no evidence from review of the investigation to determine why the patient attempted to get up, if the patient attempted to call for assistance and if call was answered, fall risk assessments performed, preventions implemented based on risk assessments, and was rounding being completed per hospital policy prior to the incident being closed.


- On 12/20/18, Patient #8 was found on floor face down in front of his/her wheelchair. No chair alarm activated. A severity level of two "minor harm/damage" was noted. There was no evidence from the investigation follow-up was completed to determine the outcome of the patient's injuries. There was no evidence from review of the investigation to determine why the patient attempted to get up from the wheelchair, if the patient attempted to call for assistance and if call was answered, fall risk assessments performed, preventions implemented based on risk assessments, and was rounding being completed per hospital policy prior to the incident being closed.


- On 11/18/18, Patient #4 was found lying on his/her right side on floor under sink after falling out of his/her wheelchair. Chair alarm had activated. A severity level of two "minor harm/damage" was noted. The investigation failed to document evidence of injuries. Report noted "processes were in placed and followed". There was no evidence from review of the investigation to determine why the patient attempted to get up from the wheelchair, if the patient attempted to call for assistance and if call was answered, fall risk assessments performed, preventions implemented based on risk assessments, and was rounding being completed per hospital policy prior to the incident being closed.


- On 11/13/18, Patient #7 was found on the floor face down "in a puddle of blood" coming from his/her nose. Hematoma was noted to the left forehead and lateral rotation to the left leg. Patient was transported by EMSA to the ED for CT of the head and hip x-rays. A severity level of two "minor harm/damage" was noted. There was no evidence from the investigation follow-up was completed to determine the outcome of the patient's injuries. Report noted this had been a repeated fall and patient had been on the fall prevention program at the time of the fall. There was no evidence from review of the investigation to determine if the patient attempted to call for assistance prior to getting up and if the call was answered, was fall risk assessments being performed, preventions implemented based on risk assessments, and whether rounding was being completed and documented in the patient's medical record per hospital policy prior to the incident being closed.


- On 11/11/18, at 3:10 am, Patient #6 was found on floor due to attempting to get out of bed. Patient stated he/she had "slid right off of the bed". Report noted three skin tears. APRN notified, examined patient and ordered a CT scan. Reported noted this had been a repeated fall and patient had been on the fall prevention program at the time of the fall. There was no evidence from review of the investigation to determine why the patient attempted to get out of bed, if the patient attempted to call for assistance prior to getting out of bed and if the call was answered, was fall risk assessments being performed, preventions implemented based on risk assessments, and whether rounding was being completed and documented in the patient's medical record per hospital policy prior to the incident being closed.


- On 10/27/18, at 8:26 pm, Patient #1 was found on the floor in the bathroom shower unable to reach the emergency light. Patient stated, he/she had attempted to get to the bathroom due to being constipated, became dizzy, fell, and landed in the shower. The patient was noted to have a "golf ball size knot" on the posterior right side of his/her head with a bleeding laceration, and a skin tear to the right forearm. Patient was transported to the ED by EMSA. Report noted this had been a repeated fall and the patient had been on the fall prevention program at the time of the fall. A severity level of two "minor harm/damage" was noted. There was no evidence from the investigation that a follow-up was completed to determine the outcome of the patient's injuries. There was no evidence from review of the investigation to determine if the patient attempted to call for assistance prior to getting out of bed and if the call was answered, was fall risk assessments being performed, preventions implemented based on risk assessments, and whether rounding was being completed and documented in the patient's medical record per hospital policy prior to the incident being closed.


- On 10/18/18, at 10:50 am, Patient #2 was at the sink performing grooming activities with a gait belt in place and slip socks on when he lost his balance and struck his right shoulder on the sink or wall. Patient reported an increase of right shoulder pain. A severity level of two "minor harm/damage" was noted. There was no evidence from the investigation follow-up was completed to determine any treatment and outcome of the patient's injuries.

- On 10/05/18 at 10:30 am, Patient #5 was found on floor with bleeding head wound. Chair alarm sounding was noted. Patient was transported to the ED and was admitted. Report noted that this had been a repeated fall and the patient had been on the fall prevention program at the time of the fall. A severity level of two "minor harm/damage" was noted. There was no evidence from the investigation that a follow-up was completed to determine the outcome of the patient's injuries. There was no evidence from review of the investigation to determine why the patient attempted to get out of the chair, if the patient attempted to call for assistance prior to getting out of the chair and if the call was answered, was fall risk assessments being performed, preventions implemented based on risk assessments, and whether rounding was being completed and documented in the patient's medical record per hospital policy prior to the incident being closed.


- On 10/02/18, at 2:10 pm, Patient #3 was found down lying at his/her bedside after an unwitnessed fall. Report noted no alarm was sounding at the time of the patient's fall. There was no evidence from review of the investigation to determine why the patient attempted to get out of bed, if the patient attempted to call for assistance prior to getting out bed and if the call was answered, was fall risk assessments being performed, preventions implemented based on risk assessments, and whether rounding was being completed and documented in the patient's medical record per hospital policy prior to the incident being closed.


- On 06/08/18, at 9:55 am, Patient #12 was found face down in the bathroom bleeding from his temple, not responding to verbal cues. Patient was transported to ED via EMSA. Report noted that patient's family was notified by hospital that the patient had "two small brain bleeds and had been admitted into ICU". A severity level of three "permanent harm/damage" was noted. There was no evidence from review of the investigation to determine why the patient attempted to get out of bed, if the patient attempted to call for assistance prior to getting out bed and if the call was answered, was fall risk assessments being performed, preventions implemented based on risk assessments, and whether rounding was being completed and documented in the patient's medical record per hospital policy prior to the incident being closed.


On 02/01/19, at 8:48 am, Staff B stated he/she "re-educated" nursing staff regarding the importance of completing the "post-fall huddle form" after a patient falls. Staff B stated, the hospital had hired more than 20 new staff members in the months of October and November. Staff B stated, the fall committee did not conduct any type of analysis for Patient #7 or #12 to determine the cause of the patients' injuries, any process issues, or the need to implement preventative action plans. Staff B stated, he/she acknowledged there was no evidence of post-fall huddles for the months of October and November. Staff B stated, he/she educated staff through floor huddles that occurred daily.


On 02/01/19, at 9:16 am, Staff C stated, fall committee members discussed no post-fall huddles during committee in October. Staff C stated, he/she would review an incident report and then refer it back to the nurse or therapy manager for investigation. Staff C stated, the manager would perform an investigation to determine what happened to the patient that led to the fall, if the bed/chair alarm was activated, any injuries, who was notified, and if the patient was sent out. Staff C stated, completion of the post-fall huddle form was not part of the investigation. Staff C stated, he/she did not follow-up to make sure a post-fall huddle had been completed prior to closing the incident.


On 02/01/19, at 10:34 am, Staff H stated, the hospital performed a Leave of Absence (LOA) huddle for patients who are transferred out of the hospital to review why a patient was sent out of the hospital, whether the care provided was appropriate, and track/trend in effort to recognize a pattern or issue such as falls or a particular physician. Staff H stated, during a review once a clinical issue has been discussed the case would be handed back over to the local team to look at why a patient fell and decide if the event warranted a root cause analysis to determine any process failures. Staff H stated, it would be important to take care of the acute issues initially and then determine any potential process failures that may have led to the event and injuries.

Based on record review and interview, the hospital failed to identify unresolved complaints as grievances; 18 of 20 unresolved complaints were not reviewed or investigated by the Grievance Review Committee (GRC).

This failed practice resulted in the likelihood that unresolved complaints, registered by patients (or patient representatives), would not be recognized as grievances by the hospital, and patients (or patient representatives) would not receive a written response from the hospital.


Findings:


Review of hospital policy titled "Patient/Family Complaint, revised 08/17" showed that patient complaints that were not resolved immediately, at the time of the complaint by the staff present, would be sent to the GRC. The policy failed to define "Grievance".


Review of Hospital policy titled "Grievance Resolution, revised, 08/01/17" stated, the Risk Manager would refer unresolved complaints and grievances to the GRC. The policy stated the GRC would perform an investigation and provide a written response to the patient (or patient representative) that would include, hospital contact name, steps taken on behalf of the patient to investigate the grievance, and results of the investigation. The policy failed to define "Grievance".


Review of the hospital complaint log showed 18 (Pt #17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, and 34) of 20 unresolved complaints that failed to show a grievance investigation or a written response from the hospital regarding the outcome of the grievance. Patients not having a grievance investigation had complaints that were not resolved immediately, at the time of the complaint, by the staff present.

Patient #17: 11/28/18, complaints regarding treatment and bedside care.

Patient #18: 12/02/18, complaints regarding medication administration errors.

Patient #19: 12/05/18, complaints regarding bedside care and assistance.

Patient #20: 10/01/18, complaints regarding no treatment for infection.

Patient #21: 11/12/18, complaints regarding bedside care and unmet needs.

Patient #22: 09/14/18, complaints regarding delay in care, and medication error.

Patient #23: 08/14/18, complaints regarding bedside care, edema in legs.

Patient #24: 08/10/18, complaints regarding bedside care, medication errors.

Patient #25: 07/17/18, complaints regarding lack of care and non-communication.

Patient #26: 06/25/18, complaints regarding quality of care and staff unresponsive to needs.

Patient #27: 06/17/18, complaints regarding fear of nursing staff and rough treatment.

Patient #28: 06/08/18 complaints regarding quality of care and lack of hygiene.

Patient #29: 03/12/18 complaints regarding lack of pain control and poor treatment.

Patient #30: 06/06/18, complaints regarding bedside care and patient assistance.

Patient #31: 03/02/18, complaints regarding lack of pain control and poor bedside care.

Patient #32: 02/27/18, complaints regarding medication and patient fall.

Patient #33: 02/20/18 complaints regarding poor hygiene no response to complaints.

Patient #34: 01/29/18 complaints regarding not turning patient and bed sore.


On 01/31/19 1:52 pm, Staff C (Director of Quality) stated the hospital did not always take unresolved complaints through the grievance process. Staff C confirmed that there were no grievance investigations and there were no written responses to 18 of 20 patients reviewed.

Based on record review and interview, the hospital failed to ensure one (Staff #M) of one agency staff nurse was orientated to the hospital policies and procedures before they provided patient care.

This failed practice had the likelihood to affect all patients due to failing to follow hospital policy in a disaster.

Findings:

Review of the personnel file for Staff #M showed no evidence of orientation to hospital policy and procedure.

An interview with the Chief Nursing Officer (CNO) was conducted on 02/01/19 at 1:00 p.m. The CNO stated, agency staff receive orientation of hospital policies and procedures, training, and competency evaluations before they provide patient care. The CNO stated the hospital did not have evidence of Staff #M having orientation of hospital policy and procedures.