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Based on document review and interview, the facility failed to investigate, notify and respond in writing to a complaint/grievance (Tag 119), and failed to ensure patients were provided care in a safe setting by implementing appropriate fall risk interventions (Tag 144).

The cumulative effects of the above prevented the facility from protecting and promoting patient rights.

Based on document review and interview, the registered nurse failed to follow the facility policy and procedure related to fall preventions such as bed alarms being activated for three (3) of thirteen (13) medical record's (MR's) reviewed (Patient # 1, Patient # 2, Patient # 3), failed to respond to telemetry monitor alarms for one (1) of six (6) closed MR's reviewed (Patient # 1), failed to complete neurological checks after a patient fall in which an injury was sustained for one (1) of six (6) closed MR's reviewed (Patient # 2), failed to complete a post fall huddle with the staff for two (2) of thirteen (13) MR's reviewed (Patient # 1, Patient # 3), failed to ensure a telemetry monitoring strip was printed and analyzed for one (1) of six (6) closed MR's reviewed (Patient # 1), failed to ensure a critique was completed for one (1) of three (3) closed MR's reviewed for Code Blue (Patient # 1), and failed to ensure the circumstances prior to a patient's death was accurately reported to the coroner upon a patient's death for one (Patient # 1) of three MR's reviewed for deaths (see tag A395), the facility failed to ensure the nursing staff followed the policy and procedure related to developing and updating the patients plan of care (treatment plan) for one (Patient # 1) of six patient closed medical records (MR's) reviewed (see tag A396).

The cumulative effects of the above prevented the facility from protecting and promoting patient care.

Based on document review and interview, the facility failed to ensure a grievance was investigated, the complainant was notified of a plan of action and provision of a written response to a grievance for 1 of 6 incidents reviewed. (Family member #1)

Findings include;

1. Facility policy titled "Complaints and Grievances" last reviewed/revised 2/2018 indicated the following: "...POLICY: The mission ...is to promote quality, value and optimal outcomes of all services provided to our patients. Our vision and the inherent core values support patient rights, respect for human dignity and the assurance of justice. ...Every complaint and grievance received is managed in a manner that safeguards the confidentiality of the patient, the family, and the nature of the complaint or grievance itself, including those complaints or grievances considered "insignificant". The complaint and grievance process shall always incorporate a multi-disciplinary approach to its investigation to encourage fair, accurate and unbiased examination of problems with well-researched recommendations for solutions. All complaints and grievances are reported. ...A grievance is a formal or informal written or verbal complaint that is made by the patient, or the patient's representative, when a patient issue cannot be resolved promptly by staff present. Any complaint not resolved promptly by staff present is to be considered a grievance. ...If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postpones for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. ...COMPLIANCE GUIDELINES: 1. Grievances (complaints) may be verbal or written. 2. Grievances may be brought by an individual or through patient and family groups. 3. A grievance is acknowledged, investigated, and the complainant apprised of progress toward resolution. ...PROCEDURE:
...3. Record the date, resident/family name, and issues or concern on the center complaints/grievance log. 4. Assign the appropriate Department Head to investigate. 5. Investigate to validate the complaint/grievance. 6. Notify patient and/or family/responsible party of progress. Typically, a response time of seven days is appropriate; most grievances should be resolved within that amount of time. 7. If an investigation cannot be completed or a grievance cannot be resolved within seven days, the patient or the patient's representative should be informed that the process is ongoing and that he or she will receive a written response within a specified time period according to organizational policy. 8. In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion. 9. When the grievance is resolved ...Written responses should be sent even if appropriate staff members meet with the patient and family members and resolve the grievance during the discussion. ...11. ...The hospital must attempt to resolve all grievances as soon as possible. 12. Determine resolution. ...14. Record the date resolved and resolution on the form. ...17. Conduct on-going follow-up to validate resolution is maintained and the patient and family member/responsible parties are satisfied with the resolution ...."

2. Facility policy titled "Patient Rights and Responsibilities" last reviewed/revised 9/25/18 indicated the following: "...26. ...The grievance committee will review each grievance and provide you with a response within 7 days. The written response will contain the name of a person to contact at the hospital, the steps take to investigate the grievance, the results of the grievance process, and the date of the completion of the grievance process. Concerns related to quality of care or premature discharge will also be referred to the appropriate Utilization and Quality Control Peer Review Organization (PRO) ...."

3. Facility policy titled "Plan for Provision of Care" last reviewed/revised 12/2016 indicated the following: " ...Quality Management Department: ...Although the Quality Management department does not provide direct patient care, the primary goal of the department is to ensure the safe, appropriate, effective, and responsible care of all patients. ...The DQM [Director of Quality and Risk Management] serves as the Risk Manager and assists to ensure the safety of staff, visitors, and patients by investigating and disseminating related information on all employee/patient/visitor incidents within the facility. The DQM is responsible for ...participating in investigation and evaluation of safety and risk hazards ...."

4. A review of an incident documentation from A#1 (Director of Quality) dated 9/14/18 at 6:30 p.m., it indicated communication with FM#1 (family member of patient #11) and FM#2 (family member of patient #11) related to patient #11 began on 9/12/18, after he/she was informed during a flash morning meeting. The communication documentation indicated on 9/12/18 that FM#1 had many complaints about the care of patient #11, which included but was no limited to patient had a deep vein thrombosis that staff kept touching and that it hurt and was making the patient restless and start thrashing. FM#1 did not want the patient restrained and preferred him/her and FM#2 sit by his/her side and ensure the patient would not pull at his/her trach site. FM#1 had a concern that the patient would be over-sedated and could not participate in therapy and concern related to the physician ordering Haldol and the risks of using it. On 9/14/18 at 10:15 a.m., FM#1 brought additional concerns related to patient #11's care, which included but were not limited to patient #11 not having a working call light, his/her bed was wet something wrong with the Foley, took 1.5 hours to get patient #11's bed changed and his/her pulse ox came off, causing a loud beeping and it took staff 15 minutes to respond.. The documentation addressed the medication, restraint concerns and included multidisciplinary team approach with the physicians, pharmacist, quality director, FM#1 and FM#2. The incident documentation lacked documentation addressing/investigating the additional patient care concerns for patient #11. The facility lacked documentation of addressing/investigating the additional patient care concerns for patient #11 or a written response within 7 days of receiving the grievance.

5. A review of communication documentation provided by A#4 (Nurse Manager) on 9/27/18 at 4:06 p.m., indicated an email from FM#1 to him/her on 9/17/18 at 1:12 p.m. of FM#1's specific concerns related to
patient #11's care and that he/she wanted to touch base with A#4. The email contained additional concerns not mentioned in the incident communication completed by A#1 on 9/14/18, along with previous patient care concerns The additional concerns included but were not limited to: a) Staff moving patient #11 in bed and in the process popped the balloon cuff in his/her trach on 9/10/18. b) FM#1 requested a meeting with the charge nurse that evening, so a report could be taken of the event but the information was not even passed on to day shift and a report was not completed. c) A#1 not addressing the additional patient care concerns/issues, which included but was not limited to call light not working for 9 days and no response to alarms. The facility lacked documentation of addressing/investigating the additional patient care concerns for patient #11 or a written response to the grievance within 7 days of receiving the grievance.

6. An interview on 9/27/18 at 4:06 p.m. with A#4, he/she indicated that they had spoken with FM#1 on
9/16/18 via the telephone and A#4 had felt that all concerns were addressed and the complaint/grievance was resolved. A#4 indicated FM#1 sent him/her a complaint via email on 9/17/18, so that A#4 would know all
of FM#1's previous concerns for his/her own information and that A#4 met with A#6 (Chief Executive Officer) and A#3 (Chief Clinical Officer). A#4 indicated he/she had spoken with FM#2 on 9/17/18 and they indicated to him/her that care was good for patient #11. He/she indicated he/she then spoke with FM#1 on 9/17/18 as well and that they indicated the concerns were resolved and that they wanted to move past that. Care has been excellent, had some concerns on night shift.

7. An interview on 9/27/18 at 4:33 p.m. with A#8 (Vice President of Quality and Risk Management), he/she indicated the complaint related to patient #11 would be considered a grievance.

8. An interview on 9/27/18 at 4:48 p.m. with A#8, he/she indicated that if a complaint cannot be resolved within 24 hours then it would be moved into the grievance process and put it into incident reporting and sent to the DQM (Director of Quality Management). A#8 indicated that the grievance is viewable to those assigned it by the DQM. He/she indicated the investigation and follow-up of the grievance would occur and depending on the allegations would include physicians and department heads. He/she indicated they would also bring in any staff that was assigned that patient, have a conversation with them and depending on what is shared would determine the next step of the grievance process. A#8 further indicated that the patient's medical record would be reviewed to see what was documented by the several disciplines.

9. An interview on 9/27/18 at 5:05 p.m. with NS#5 (Registered Nurse Supervisor), he/she indicated they had spoken with FM#2 on 9/19/18 and FM#2 indicated no concerns related to patient #11's care and the medication concern had been addressed. NS#5 indicated on 9/23/18, FM#1 had called and spoke with him/her due to needing a consent for a PICC (peripherally inserted central catheter) line for patient #11 and FM#1 had indicated to him/her that they had no concerns. NS#5 further indicated he/she had spoken with FM#1 on 9/23/18 on night shift and he/she did not express any concerns.

10. An interview with FM#2 on 9/27/18 at 6:40 p.m., he/she indicated no patient care concerns related to dayshift while he/she was there and the only thing a concern was the call light not working and the staff tried several times to fix it. FM#2 indicated he/she had spoken with A#24 (Case Manager) today and patient #11 will graduate next week to a rehabilitation facility. FM#2 indicated he/she had spoken with A#4 last week and he/she would resolve any concerns. FM#2 indicated A#4 had asked what they felt quality service was and he/she would make sure that's what the patient would receive.

11. An interview with FM#1 on 9/27/18 at 6:45 p.m. via telephone conversation, he/she indicated they cannot say the complaints/grievance was resolved. FM#1 indicated he/she had spoken with several people multiple times related to his/her concerns. The staff FM#1 had spoken with included A#6 - two times, A#1 -multiple times, A#4 via text, telephone, email combined a total of 4 times and 1 of those times was today, which was approximately an hour ago. FM#1 indicated that FM#2 has spoken to physicians and FM#1 has spoken with MS#2 (Internist) and he/she was going to give Haldol to the patient no matter what.


35731

Based on document review and interview, the facility failed to ensure a grievance was investigated, the complainant was notified of a plan of action and provision of a written response to a grievance for 1 of 6 incidents reviewed. (Family member #1)

Findings include;

1. Facility policy titled "Complaints and Grievances" last reviewed/revised 2/2018 indicated the following: "...POLICY: The mission ...is to promote quality, value and optimal outcomes of all services provided to our patients. Our vision and the inherent core values support patient rights, respect for human dignity and the assurance of justice. ...Every complaint and grievance received is managed in a manner that safeguards the confidentiality of the patient, the family, and the nature of the complaint or grievance itself, including those complaints or grievances considered "insignificant". The complaint and grievance process shall always incorporate a multi-disciplinary approach to its investigation to encourage fair, accurate and unbiased examination of problems with well-researched recommendations for solutions. All complaints and grievances are reported. ...A grievance is a formal or informal written or verbal complaint that is made by the patient, or the patient's representative, when a patient issue cannot be resolved promptly by staff present. Any complaint not resolved promptly by staff present is to be considered a grievance. ...If a verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postpones for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution, then the complaint is a grievance for the purposes of these requirements. A complaint is considered resolved when the patient is satisfied with the actions taken on their behalf. ...COMPLIANCE GUIDELINES: 1. Grievances (complaints) may be verbal or written. 2. Grievances may be brought by an individual or through patient and family groups. 3. A grievance is acknowledged, investigated, and the complainant apprised of progress toward resolution. ...PROCEDURE: ...3. Record the date, resident/family name, and issues or concern on the center complaints/grievance log. 4. Assign the appropriate Department Head to investigate. 5. Investigate to validate the complaint/grievance. 6. Notify patient and/or family/responsible party of progress. Typically, a response time of seven days is appropriate; most grievances should be resolved within that amount of time. 7. If an investigation cannot be completed or a grievance cannot be resolved within seven days, the patient or the patient's representative should be informed that the process is ongoing and that he or she will receive a written response within a specified time period according to organizational policy. 8. In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion. 9. When the grievance is resolved ...Written responses should be sent even if appropriate staff members meet with the patient and family members and resolve the grievance during the discussion. ...11. ...The hospital must attempt to resolve all grievances as soon as possible. 12. Determine resolution. ...14. Record the date resolved and resolution on the form. ...17. Conduct on-going follow-up to validate resolution is maintained and the patient and family member/responsible parties are satisfied with the resolution ...."

2. Facility policy titled "Patient Rights and Responsibilities" last reviewed/revised 9/25/18 indicated the following: "...26. ...The grievance committee will review each grievance and provide you with a response within 7 days. The written response will contain the name of a person to contact at the hospital, the steps taken to investigate the grievance, the results of the grievance process, and the date of the completion of the grievance process. Concerns related to quality of care or premature discharge will also be referred to the appropriate Utilization and Quality Control Peer Review Organization (PRO) ...."

3. Facility policy titled "Plan for Provision of Care" last reviewed/revised 12/2016 indicated the following: " ...Quality Management Department: ...Although the Quality Management department does not provide direct patient care, the primary goal of the department is to ensure the safe, appropriate, effective, and responsible care of all patients. ...The DQM [Director of Quality and Risk Management] serves as the Risk Manager and assists to ensure the safety of staff, visitors, and patients by investigating and disseminating related information on all employee/patient/visitor incidents within the facility. The DQM is responsible for ...participating in investigation and evaluation of safety and risk hazards ...."

4. A review of an incident documentation from A#1 (Director of Quality) dated 9/14/18 at 6:30 p.m., it indicated communication with FM#1 (family member of patient #11) and FM#2 (family member of patient #11) related to patient #11 began on 9/12/18, after he/she was informed during a flash morning meeting. The communication documentation indicated on 9/12/18 that FM#1 had many complaints about the care of patient #11, which included but was not limited to patient had a deep vein thrombosis that staff kept touching and that it hurt and was making the patient restless and start thrashing. FM#1 did not want the patient restrained and preferred him/her and FM#2 sit by his/her side and ensure the patient would not pull at his/her trach site. FM#1 had a concern that the patient would be over-sedated and could not participate in therapy and concern related to the physician ordering Haldol and the risks of using it. On 9/14/18 at 10:15 a.m., FM#1 brought additional concerns related to patient #11's care, which included but were not limited to patient #11 not having a working call light, his/her bed was wet, something wrong with the Foley, took 1.5 hours to get patient #11's bed changed and his/her pulse ox came off, causing a loud beeping and it took staff 15 minutes to respond. The documentation addressed the medication, restraint concerns and included multidisciplinary team approach with the physicians, pharmacist, quality director, FM#1 and FM#2. The incident documentation lacked documentation addressing/investigating the additional patient care concerns for patient #11. The facility lacked documentation of addressing/investigating the additional patient care concerns for patient #11 or a written response within 7 days of receiving the grievance.

5. A review of communication documentation provided by A#4 (Nurse Manager) on 9/27/18 at 4:06 p.m., indicated an email from FM#1 to him/her on 9/17/18 at 1:12 p.m. of FM#1's specific concerns related to
patient #11's care and that he/she wanted to touch base with A#4. The email contained additional concerns not mentioned in the incident communication completed by A#1 on 9/14/18, along with previous patient care concerns The additional concerns included but were not limited to: a) Staff moving patient #11 in bed and in the process popped the balloon cuff in his/her trach on 9/10/18. b) FM#1 requested a meeting with the charge nurse that evening, so a report could be taken of the event but the information was not even passed on to day shift and a report was not completed. c) A#1 not addressing the additional patient care concerns/issues, which included but was not limited to call light not working for 9 days and no response to alarms. The facility lacked documentation of addressing/investigating the additional patient care concerns for patient #11 or a written response to the grievance within 7 days of receiving the grievance.

6. In interview on 9/27/18 at 4:33 p.m. with A#8 (Vice President of Quality and Risk Management), he/she indicated the complaint related to patient #11 would be considered a grievance.

7. In interview on 9/27/18 at 4:48 p.m. with A#8, he/she indicated that if a complaint cannot be resolved within 24 hours then it would be moved into the grievance process and put it into incident reporting and sent to the DQM (Director of Quality Management). A#8 indicated that the grievance is viewable to those assigned it by the DQM. He/she indicated the investigation and follow-up of the grievance would occur and depending on the allegations would include physicians and department heads. He/she indicated they would also bring in any staff that was assigned that patient, have a conversation with them and depending on what is shared would determine the next step of the grievance process. A#8 further indicated that the patient's medical record would be reviewed to see what was documented by the several disciplines.

8. In interview with FM#2 on 9/27/18 at 6:40 p.m., he/she indicated no patient care concerns related to dayshift while he/she was there and the only concern was the call light not working.

9. In interview with FM#1 on 9/27/18 at 6:45 p.m. via telephone conversation, he/she indicated they cannot say the complaints/grievance was resolved. FM#1 indicated he/she had spoken with several people multiple times related to his/her concerns. The staff FM#1 had spoken with included A#6 - two times, A#1 -multiple times, A#4 via text, telephone, email combined a total of 4 times and 1 of those times was today, which was approximately an hour ago. FM#1 indicated that FM#2 has spoken to physicians and FM#1 has spoken with MS#2 (Internist) and he/she was going to give Haldol to the patient no matter what.

Based on document review and interview, the facility failed to ensure patients were provided care in a safe setting by failing to implement fall risk interventions in two (2) instances. (Patient # 1 & Patient # 2).

Findings include:

1. Review of the hospital policy titled, "Patient Rights and Responsibilities", effective date 04/01/2010, indicated "You have the right to: Receive care in a safe setting, free from mental, physical abuse and neglect. This policy was last revised on 09/25/2018.

2. Review of the hospital policy titled, "Fall Prevention and Management Program", effective date 09/2006, indicated the nursing staff should "assess patient's fall risk upon admission, each shift and change in status". High risk fall prevention interventions are designed to be "implemented for patients" with multiple fall risk factors and those "who have fallen" to help "reduce severity of injuries" due to falls as well as "prevent falls from reoccurring". Consider use of "safety technology" for fall prevention such as "bed" alarm and "alarms at exits". This policy was last revised on 03/2018.

3. Review of the hospital policy titled, "Suspected Patient Abuse/Neglect", effective date 12/2014, indicated the definition of neglect to be an "action(s) by an employee contrary to prescribed treatment" and failure to protect the patient from health, "safety hazards" and/or "unattended for long periods". This policy was last revised on 02/2018.

4. Review of the hospital policy titled, "Guidelines for Nursing Care", effective date 10/2010, indicated to ensure quality patient care, certain standards of care must be upheld. The following "basic nursing task" designates the minimum frequency with which the task must be performed to maintain quality of care: "telemetry alarms" should be "on at all times" with parameters individualized per patient "every shift". This policy was last revised on 12/2016.

5. Review of the hospital policy titled, "Plan for Provision of Care", effective date 04/2007, indicated the "purpose of the plan is to provide a structure by which defined standards of patient care can be systematically organized, monitored, and evaluated". The goal "is to provide individualized, planned, and appropriate care" in a setting that supports the patient's care, treatment, therapy goals and "specific needs". A registered nurse (RN) will "define, direct, supervise, and evaluate the nursing care of each patient". The "Plan of Care is updated as patient needs change". This policy was last reviewed on 12/2016.

6. Review of the hospital patient's handout titled, "Notice of Privacy Rights and Responsibilities-Your Information. Your Rights. Our Responsibilities", effective date 09/23/2013, indicated in the attachment on pg 2 of 4: "Receive care in a safe setting".

7. Review of the signed "Job Description and Competencies" dated 06/25/2018 for P # 4 (Telemetry Monitor Tech), indicated the position summary was "for continual monitoring of telemetry units and promptly alerting appropriate personnel of significant changes in readings". Additional responsibilities included "Promotes and protects patient's rights."

8. Review of the signed "Job Description and Competencies" dated 12/19/2017 for P # 5 (Unit Secretary), indicated the position summary was "Responsible for directing the orderly flow of unit and patient related data. Responsible for communications through the answering and initiation of telephone calls." The job function "to answer telephone/call system at nursing station, screening calls and dispersing to the appropriate staff". Additional responsibilities included "Promotes and protects patient's rights."

9. Review of the closed MR for patient # 1 indicated the following:
A. The patient was a 79 y/o (year/old) admitted from H # 3 (Acute Care Hospital) to H # 1 (Long Term Care) Hospital on 08/23/2018 at 7:10 pm.
B. The Pre-Admission Assessment Form completed on 08//23/2018 at approximately 4:17 pm by CL # 1 (Clinical Liaison), indicated the patient to be alert and orientated times three (3). The patient's treatment plan included the following precautions: safety, aspiration, "bed alarm and fall". The patient was documented as a moderate assist.
C. The patient's diagnoses included, but were not limited to, acute and chronic respiratory failure, COPD (Chronic Obstructive Pulmonary Disease) exacerbation, acute and chronic diastolic CHF (Congestive Heart Failure), anemia, hypertension, hypothyroidism, debility, reactive depression, alzheimer's dementia without behavioral disturbance.
D. The Initial Care Plan dated 08/23/2018 lacked "safety-falls" interventions and "artificial airway" interventions. The Care Plan was updated on 09/13/2018 which included, but were not limited to, the problems "Safety/Falls and "Artificial Airway". The interventions included "bed alarm settings are appropriate for patient needs, bed alarm activated when patient in bed", and the objective for RT (respiratory therapy) was to "protect and secure" the airway and to "maintain" a "patent airway".
E. Review of the Patient Care Notes dated 08/28/2018 by NS # 7 (RN) at approximately 2:00 am, indicated the "bed alarm on" due to while sitting in room charting "looked over" and "patient was sitting on the side of the bed". The patient was assisted to a lying position and instructed as to why he/she can "NOT JUST GET UP".
F. Review of the Patient Care Notes dated 09/08/2018 by NS # 3 at approximately 8:00 pm, indicated the patient had an "unwitnessed fall". The patient was observed by a PCT (patient care tech) to be sitting up against the bed with non-skid socks on. Patient was assisted to bed and the "bed alarm was turned on".
G. Review of the Patient Care Notes dated 09/11/2018 by NS # 4 (RN) at approximately 12:02 am, indicated the patient was "found slumpt over side of bed blocking tracheal opening". The patient was placed back in bed and "found to be pulseless and in asystole". A code blue was called and CPR (Cardiopulmonary Resuscitation) was initiated.

10. Review of patient # 1's "Post Fall Review" dated 09/10/2018 (no time documented), by A # 1 (Director of Quality), indicated patient # 1 had an unwitnessed fall on 09/08/2018 at approximately 8:00 pm. "No action indicated" was checked. The "Post Fall Huddle" dated 09/08/2018 at approximately 11:00 pm by NS # 3 (RN Supervisor), indicated the "recommendation" was to "have bed alarm on".

11. Review of patient # 1's "Post Fall Review" dated 09/12/2018 (no time documented), by A # 1, indicated patient # 1 was found at 12:02 am "on knees facing the bed at the left side of the foot of the bed by the nursing supervisor" and a "code" was called. The action "Physician Review Required" was checked and indicated completed by MS # 3 (Physician) "via phone" on 09/17/2018.

12. Review of the closed MR for patient # 2 indicated the following:
(A) The patient was a 68 year old admitted on 8/23/18 at 1800 hours. Admit diagnoses included but were not limited to acute on chronic systolic congestive heart failure and cerebrovascular accident.
(B) A review of the patient's care plans indicated the following: " ...Problem 3. SAF - SAFETY - FALLS (ACTIVE) Assigned: 8/25/18. Objective: SAF - NO INJURY ...(ACTIVE) Assigned 8/25/18. Intervention: *ANTICIPATE PATIENT NEEDS (ACTIVE) Assigned: 8/25/18.
*CALL LIGHT PLACED WITHIN REACH OF PATIENT (ACTIVE) Assigned: 8/25/18.
*BED ALARM ACTIVATED WHEN PATIENT IN BED (ACTIVE) Assigned: 8/25/18.
*KEEP ALL ITEMS WITHIN PATIENTS REACH (ACTIVE) Assigned: 8/25/18.
*BED ALARM SETTINGS ARE APPROPRIATE FOR PATIENT NEEDS (ACTIVE) Assigned: 8/25/18.
*EDUCATE PATIENT IN USE OF CALL BELL (ACTIVE) Assigned: 8/25/18 ...."
(C) The "Nursing LTAC [Long-term Acute Care Hospital] Shift Assessment-Flowsheet" dated 9/12/18 at 0800 hours indicated the patient had generalized weakness, was dependent for activities of daily living, best verbal response was confused conversation, but able to answer questions, had a indwelling Foley catheter and had a Morse Fall Risk score of 60. A fall risk level of 45 or greater equals high risk and action was to implement high risk fall precautions.
(D) The "Patient Care Notes" dated 9/12/18 at 1535 hours indicated the following: ...Pt [Patient] found down on floor. NS#1 (Registered Nurse) primary RN [Registered Nurse], called to room and Rapid Response Protocol initiated. Pt's head is actively bleeding: Pressure is held to site and position of head maintained. Visible laceration noted.
(E) The "Patient Care Notes" dated 9/12/18 at 1602 hours indicated the following: " ...C-collar applied to pt and pt successfully log rolled onto back board. Pt returned to cart in preparation of transfer to CT."
(F) A physician order dated 9/12/18 at 1602 hours indicated the following: " ...CT SOFT TISSUE NECK ...Start: 9/12/18 [at] 1601 [hours] Priority: Stat Frequency: ONE TIME ...Comments: post fall ...." and was ordered by MS#2.
(G) A physician order dated 9/12/18 at 1602 hours indicated the following: " ...CT HEAD WITHOUT CONTRAST ...Start: 9/12/18 [at] 1601 [hours] Priority: Stat Frequency: ONE TIME ...Comments: post fall ...." and was ordered by MS#2
(H) The results of CT of head without contrast indicated the following: " ...Exam Time: 09/12/2018 [at] 4:52 PM [p.m.] Reason for Exam: History of falling Diagnosis: Status post fall ...Examination: CT Head Without Contrast ...Additional History: Fell hit back of head. No loss of consc. [consciousness] ...Comparison: 8/18/2018 ...IMPRESSION: 1. New right occipital lobe ischemic infarct. 2. Maturing right frontal lobe ischemic infarct. 3. Old small left occipital lobe ischemic infarct ...."
(I) The results of CT of cervical spine without contrast indicated the following: " ...Exam Time: 09/12/2018 [at] 5:27 PM [p.m.] Reason for Exam: History of falling Diagnosis: Status post fall
...Examination: CT Cervical Spine Without Contrast ...Additional History: Fell today. Denies cervical pain. ...Comparison: 8/6/2018 ...IMPRESSION: Senescent skeletal changes. Negative for fracture.

13. A review of the "RAPID RESPONSE TEAM RECORD - FALL" for patient # 2 dated 9/12/18 indicated the following: ...Room#/location: 552 Time called: 1535 [hours] RRT [Rapid Response Team] Arrival Time: 1535 [hours] Event End Time: 1610 [hours] ...In fall unwitnessed or head injury suspected, implement Neuro Checks Q15 minutes x [times] 4, Q30 x 2...." The medical record lacked documentation of neurological checks being completed as listed above.

14. A review of patient # 2's "POST FALL REVIEW" dated 9/18/18, indicated the patient had a fall on 9/12/18 at 1535 hours that resulted in a one inch laceration that was cleaned and left open to air. The review lacked documentation of the location of the laceration.

15. A review of patient # 2's "Post Fall Huddle Form" dated 9/12/18 indicated, the patient was attempting to use the restroom at the time of the fall, the patient was in the fall program with alarms, had cognitive issues, no skid free socks in place, no bed or w/c [wheelchair] alarm on at the time of the fall, the Morse Fall Risk Assessment prior to fall was 85 and post fall was 95.

16. In interview on 09/24/2018 at approximately 2:20 pm by A # 1 (Director of Quality), confirmed a "Post Fall Huddle" should have been completed for patient # 1 after the fall on 09/12/2018.

17. In interview on 09/24/2018 at approximately 3:10 pm by A # 4 (Nurse Manager), confirmed he/she had terminated the telemetry monitor tech (P # 4), and unit secretary/clerk (P # 5) after the incident which occurred on 09/12/2018 with patient # 1. The "teletech monitor tech called the unit clerk" to tell them the patient was "off the heart monitor". The unit clerk "did not tell anyone" and P # 5 (Unit Secretary/Clerk) "should have". Thirty (30) minutes later the telemetry monitor tech (P # 5) "called back" to say the patient was "still off the monitor" and at that time the RT # 3 (Respiratory Therapy) answered the phone. The "teletech should have followed up quicker than that". The "RT said something to the Charge Nurse who went in the room" with two (2) PCT's (Patient Care Tech's) and "found the patient hanging on the bed", pulseless and the "trach was out" on the bed, "obviously the patient had no oxygen on". At that time a "Code Blue" was called.

18. In interview on 09/24/2018 at approximately 4:35 pm by A # 4, confirmed that NS # 4 (Registered Nurse) had assisted patient # 1 to their BSC (bed side commode) and when NS # 4 assisted the patient "back to bed" he/she "didn't put the bed alarm on and should have".

19. In interview on 09/25/2018 at approximately 10:00 am by A # 1, confirmed "no MD [Medical Doctor] review was documented/completed", and an "MD should have reviewed this case" for patient # 1 post incident on 09/12/2018.

20. In interview with NS#1 (Registered Nurse Supervisor) on 9/25/18 at 1:03 p.m., he/she indicated patient #2 was lying face down and his/her body was in an awkward turn and the patient's whole body was on the floor. NS#1 indicated the patient had a laceration to the top of his/her head and that it was bleeding. NS#1 indicated the patient's bed alarm was not on and that he/she had not completed post fall neurological checks besides the initial neurological check right after the patient's fall, which he/she indicated was not documented.

21. In interview with N#5 (Registered Nurse Supervisor) on 9/25/18 at 2:03 p.m., he/she indicated that when a fall occurs with a head injury, the standard of care is to complete neurological checks after the fall. He/she indicated the medical record of patient #2 lacked documentation of neurological checks after his/her fall on 9/12/18.

22. In interview with A#3 (Chief Clinical Officer) on 9/26/18 at 2:15 p.m., he/she verified a lack of documentation of patient #2 having a bed exit alarm in use on 9/11/18 and 9/12/18 and was first documented as having a bed exit alarm in use was on 9/13/18 at 0930 hours.

23. In interview with NS#5 (Nurse Supervisor) on 9/26/18 at 3:52 p.m., he/she verified patient #2's medical record indicated the bed alarm was not activated during his/her fall.

24. In interview on 09/26/2018 at approximately 3:55 pm by NS # 4 who had been assigned to care for patient # 1 on 09/11/2018 night shift, confirmed he/she "forgot to turn the bed alarm on".

25. In interview on 09/27/2018 at approximately 1:20 pm by NS # 1 (Nurse Supervisor), confirmed he/she did "not say anything to the coroner about the patient being coded and being placed on the vent" (ventilator).

26. In interview on 09/27/2018 at approximately 2:00 pm with administrative staff member A # 3 (Chief Clinical Officer-CCO), confirmed speaking to NS # 6 (Nurse Supervisor) related to the "Code Blue Critique" for patient # 1 which had occurred on 09/12/2018. A # 3 confirmed that NS # 6 indicated he/she had "forgot to do the evaluation".

27. In interview on 09/27/2018 at approximately 2:05 pm with administrative staff member A # 10 (Senior Vice President (VP) Clinical Operations), confirmed that patient # 1 had not been placed on "adequate interventions" prior to the date of 09/13/2018 for "safety/falls, telemetry monitoring and tracheostomy care". There "is a problem".

28. In interview on 09/27/2018 at approximately 3:50 pm with NS # 5 (Nurse Supervisor), confirmed the "coroner should have been notified" that patient # 1 was "coded after being found unresponsive" and then "placed on a vent". We "have been trained" on the proper way to report deaths.

Based on document review and interview, the facility failed to monitor the effectiveness, safety of services and quality of care by taking immediate action to educate staff on interventions related to fall precautions which include safety equipment being activated such as bed alarms and telemetry monitors to ensure future patient safety. The facility also failed to ensure a patient's death review form and coroner report death form was completed accurately for one (1) of three (3) patient deaths reviewed. (Patient # 1)

Findings include:

1. Review of the hospital policy titled, "Reportable Events", effective date 09/2013, indicated the definition of a "Adverse Event" to be an event that has a "negative consequence of care" that results in "unintended injury" or illness, which may or may not have been preventable. The "Preventable Event" definition was an event that "could have been anticipated" and "prepared against" but occurs because of an "error" or other system failure. The "Serious Preventable Event" definition "is an adverse event that is a preventable event and "results in death...". This policy was last revised on 11/2016.

2. Review of the "Death Review" form for patient # 1 indicated the following:
A. Autopsy screening was not marked either performed or not performed.
B. Death associated with adverse event question was not completed.
C. The conclusion indicated the patient was "partially out of bed".

3. Review of the "County Coroner" form for patient # 1 indicated the following:
A. The date of birth was incorrectly documented as 09/26/1939. The patient's date of birth was 07/26/1939.
B. The question "Did a specific event lead to a death?" was not indicated yes or no.

4. Review of MS # 2 (Physician) progress note for patient # 1 dated 09/16/2018 at 8:10 am, indicated the patient was "slumped over in bed". Family decided comfort care only and remove vent (ventilator) support on "07/14".

5. In interview on 09/25/2018 at approximately 10:20 am with administrative staff members A # 1 (Director of Quality) and A # 3 (Chief Clinical Officer), confirmed "as a facility no education class related to falls and/or bed alarms have been held". The facility has created a plan "but no immediate action was taken".

6. In interview on 09/27/2018 at approximately 2:50 pm with administrative staff member A # 10 (Senior Vice President Clinical Operations), confirmed he/she believed this to be an adverse and preventable event. He/she "had concerns" with the information and completion of the review.

7. In interview on 10/08/2018 at approximately 1:40 pm with C # 1 (Chief Investigative Officer/Deputy Coroner), confirmed that the "County Coroner-To report a death" form had not been faxed to the office. According to the notes C # 2 (Deputy Coroner) had taken, he/she took the phone call from H # 1 and documented the patient had a fall on 09/12/2018 and the trach (tracheostomy) was pulled out. The documentation also indicated that MS # 2 would be willing to sign the death certificate. C # 1 had not been aware, from the documentation, that patient # 1 after falling had a "Code Blue" initiated and was placed on a ventilator. "That would be one we would look at in more detail because it was an accidental and not natural death."

Based on document review and interview, the facility failed to follow their policy ensuring the electronic report of a patient safety incident was completed in two (2) instances. (Patient # 1 and Patient # 2)

Findings include:

1. Review of the hospital policy titled, "Operational Incident Investigation and Reporting", effective date 08/2011, indicated "it is the responsibility of all employees to report...incidents that involve patients....". The "Safety Officer" in cooperation with the "Quality Management" department will "conduct an investigation" and "develop a corrective action plan" to minimize the risk of recurrence of identified incidents. This policy was last revised on 05/2016.

2. Review of the hospital policy titled, "Reportable Events", effective date 09/2013, indicated the definition of a "Adverse Event" to be an event that has a "negative consequence of care" that results in "unintended injury" or illness, which may or may not have been preventable. The "Preventable Event" definition was an event that "could have been anticipated" and "prepared against" but occurs because of an "error" or other system failure. The "Serious Preventable Event" definition "is an adverse event that is a preventable event and "results in death...". This policy was last revised on 11/2016.

3. Review of the hospital policy titled, "Plan for Provision of Care", effective date 04/2007, indicated although the "Quality Management department" does not provide direct patient care the "primary goal" of the department was to "ensure the safe, appropriate, effective, and responsible care of all patients". The Director of Quality Management (DQM) serves as the Risk Manager and assists to "ensure the safety" of staff, visitors, and "patients" by "investigating and disseminating related information on all employee/patient/visitor incidents" within the facility. The DQM "is responsible for tracking and trending incidents reports" and "participating" in the "investigation and evaluation" of the "safety and risk hazards". This policy was last reviewed on 12/2016.

4. Review of hospital policy titled, "Fall Prevention and Management Program", effective date 09/2006, indicated the assessment of the patient "post fall" by nursing staff..."complete incident report". This policy was last revised on 12/2016.

5. Review of the "POST FALL REVIEW" dated 09/12/2018 (no time documented), by A # 1 (Director of Quality/Risk Management, indicated patient # 1 was found at 12:02 am "on knees facing the bed at the left side of the foot of the bed by the nursing supervisor" and a "code" was called.

6. Review of the "POST FALL REVIEW" dated 09/18/18, indicated patient # 2 had a fall on 9/12/18 at 3:35 pm while attempting to use the restroom which resulted in a one (1) inch laceration that was cleaned and left open to air.

7. In interview on 09/24/2018 at approximately 2:23 pm with administrative staff member A # 1, confirmed incident reports were not completed for patient # 1 who had experienced a fall on the night shift on 09/11/2018 and for patient # 2 who had experienced a fall on 09/12/2018. Incident reports "should have been completed for both falls".

1. Facility policy titled "Fall Prevention and Management Program" last reviewed/revised March 2018 indicated the following: "...POLICY: A fall is defined ...as an event which results in a person coming to rest inadvertently on the ground, or floor, or some lower level. 1. All patients admitted to the inpatient setting will be assessed for fall "risk" using the Modified Morse Fall Risk on admission, each shift, change in status of the patient, and prior to patient discharge. ...4. Safety devices will be initiated when indicated according to policy as soon as possible once the patient is assessed as being "at risk" for falling. ...PROCEDURE: Risk factors are generally categorized into extrinsic (factors outside of the patient's body) and intrinsic (patient's internal, psychological factors). 1. Use this procedure to assess fall risk when the patient is initially admitted, there is a change in status, the patient is transferred to a new location, and prior to patient discharge. 2. Go to the Fall Risk Assessment to determine if there are existing "risk" factors that may affect the patient's fall risk. 3. Proceed to the indicated intervention based upon the derived score. ...High Risk Fall Interventions: These interventions are designed to be implemented for patients with multiple fall risk factors and those who have fallen. These interventions are designed to reduce severity of injuries due to falls as well as prevent falls from reoccurring. These are supplemental to the standard fall prevention interventions. Use for those who score High Risk on the Fall Risk Assessment (> [greater than] 45 on Modified Morse Fall Risk Assessment). ...Nursing staff/Rehabilitation staff: Consider use of safety technology for fall prevention: Bed and chair alarms ...."

2. Facility policy titled "PLAN FOR THE PROVISION OF CARE, TREATMENT, AND SERVICES" last reviewed/revised 12/2016 indicated the following: ...Purpose of the Plan: The purpose of the plan is to provide a structure by which defined standards of patient care can be systemically organized, monitored, and evaluated. ...2. Assessments of Patients: Accurate patient assessment is a major component of patient care. Qualified staff members assess each patient's need for care, including systemic collection and review of patient-specific data. These assessments continue throughout the patient's stay. The goal of the assessment is to determine the appropriate level of care for each patient. ...a. An initial physical, psychological, functional screening and social status assessment is conducted on each patient: ...ii. A fall risk assessment is completed along with initial assessment. ...b. Each patient is reassessed at regularly scheduled times related to the patient's course of treatment to determine response to treatment, including when a significant change occurs in the patient's condition and/or when a significant change occurs in a patient's diagnosis. ...3. Care of Patients: ...The goal is to provide individualized, planned, and appropriate care in a setting that supports the patient's care, treatment, therapy goals and specific needs. ...a. Care of patients includes a broad range of activities. ...iii. The interventions identified in the care planning process are implemented by staff in accordance with hospital policy and procedure, and the standards and scope of practice.
iv. Hospital staff is responsible for monitoring and reassessing the patient to determine to what extent the goals were reached and if the plan of care was effective. ...h. Resuscitation Services: ...In the event that a patient is found to be without a discernable pulse and/or respirations. The Code Blue process will be activated and the CPR [cardiopulmonary resuscitation] protocol will be initiated. ...The RN [Registered] Supervisor will perform a critique and forward to the Director of Nursing. ...Nursing Services: The framework for nursing at the hospital is the nursing process. The components of the process are assessment, nursing diagnosis, planning, outcome determination, implementation, and evaluation. The Chief Clinical Officer ultimately oversees all nursing related issues. ...The High Observation Unit and ICU [Intensive Care Unit] have patient care delivered by RNs. Medical-Surgical unit have patient care delivered by RNs, LPNs, Certified Nursing Assistants, Telemetry Technicians, and Unit Secretaries. All Nursing staff are competent to deliver the level of care required based on the specific clinical needs [of] the patients.
...Registered Nurses (RN): A registered nurse will define, direct, supervise, and evaluate the nursing care of each patient. ...Nursing Assistants (CNA) or PCT Patient Care Technician: The Nursing Assistant or Patient Care Technician works under the direct supervision of an RN or LPN [Licensed Practical Nurse] and assists the patients with functional activities of daily living. Telemetry Technician: The Telemetry Technician has been trained to read and report changes in ECG rhythms to the RN Supervisor... Unit Secretary: Assists with communication, paper flow, obtaining patient, and unit equipment/supplies. The unit secretary works under the direct supervision of the licensed nursing staff. Basic Clinical Activities: ...3. Intervention - These are aspects of care that are delivered to each patient as identified on assessment. Major interventions by nursing personnel include but are not limited to: ...c. Cardiac monitoring...."

3. Review of patient #2's medical record indicated the following:
(A) The patient was a 68 year old admitted on 8/23/18 at 1800 hours. Admit diagnoses included but were not limited to acute on chronic systolic congestive heart failure and cerebrovascular accident.
(B) A review of the patient's care plans indicated the following: " ...Problem 3. SAF - SAFETY - FALLS (ACTIVE) Assigned: 8/25/18. Objective: SAF - NO INJURY ...(ACTIVE) Assigned 8/25/18. Intervention: *ANTICIPATE PATIENT NEEDS (ACTIVE) Assigned: 8/25/18.
*CALL LIGHT PLACED WITHIN REACH OF PATIENT (ACTIVE) Assigned: 8/25/18.
*BED ALARM ACTIVATED WHEN PATIENT IN BED (ACTIVE) Assigned: 8/25/18.
*KEEP ALL ITEMS WITHIN PATIENTS REACH (ACTIVE) Assigned: 8/25/18.
*BED ALARM SETTINGS ARE APPROPRIATE FOR PATIENT NEEDS (ACTIVE) Assigned: 8/25/18.
*EDUCATE PATIENT IN USE OF CALL BELL (ACTIVE) Assigned: 8/25/18 ...."
(C) The "PT [Physical Therapy] Daily Note" dated 9/12/18 at 0958 hours indicated the patient was a minimal assist for sit to stand using the stand pivot type of transfer with no assistive devices used.
(D) The "Nursing LTAC [Long-term Acute Care Hospital] Shift Assessment-Flowsheet" dated 9/12/18 at 0800 hours indicated the patient had generalized weakness, was dependent for activities of daily living, best verbal response was confused conversation, but able to answer questions, had a indwelling Foley catheter and had a Morse Fall Risk score of 60. A fall risk level of 45 or greater equals high risk and action was to implement high risk fall precautions.
(E) The "Patient Care Notes" dated 9/12/18 at 1535 hours indicated the following: ...Pt [Patient] found down on floor. NS#1 (Registered Nurse) primary RN [Registered Nurse], called to room and Rapid Response Protocol initiated. Pt's head is actively bleeding: Pressure is held to site and position of head maintained. Visible laceration noted. Nasal cannual [cannula] increased from 2 L [Liters] NC [nasal cannula] to 5 L NC. Pt is able to verbalize and is oriented to self. VS [vital signs] stable: B/P [blood pressure] 134/81, HR [heart rate] 101, temp [temperature] 96 [degrees Fahrenheit] ax [axillary], 98 % o2 sat [oxygen saturation], aand [and] 18 RR [respiration rate]. MS#2 (Internist) called 2x [times], awaiting response before pt is mobilized.
(F) The "Patient Care Notes" dated 9/12/18 at 1542 hours indicated the following: " ...Head wound has stopped actively bleeding."
(G) The "Patient Care Notes" dated 9/12/18 at 1602 hours indicated the following: " ...C-collar applied to pt and pt successfully log rolled onto back board. Pt returned to cart in preparation of transfer to CT."
(H) A physician order dated 9/12/18 at 1602 hours indicated the following: " ...CT SOFT TISSUE NECK ...Start: 9/12/18 [at] 1601 [hours] Priority: Stat Frequency: ONE TIME ...Comments: post fall ...." and was ordered by MS#2
(I) A physician order dated 9/12/18 at 1602 hours indicated the following: " ...CT HEAD WITHOUT CONTRAST ...Start: 9/12/18 [at] 1601 [hours] Priority: Stat Frequency: ONE TIME ...Comments: post fall ...." and was ordered by MS#2
(J) The results of CT of head without contrast indicated the following: " ...Exam Time: 09/12/2018 [at] 4:52 PM [p.m.] Reason for Exam: History of falling Diagnosis: Status post fall ...Examination: CT Head Without Contrast ...Additional History: Fell hit back of head. No loss of consc. [consciousness] ...Comparison: 8/18/2018 ...IMPRESSION: 1. New right occipital lobe ischemic infarct. 2. Maturing right frontal lobe ischemic infarct. 3. Old small left occipital lobe ischemic infarct ...."
(K) The results of CT of cervical spine without contrast indicated the following: " ...Exam Time: 09/12/2018 [at] 5:27 PM [p.m.] Reason for Exam: History of falling Diagnosis: Status post fall
...Examination: CT Cervical Spine Without Contrast ...Additional History: Fell today. Denies cervical pain. ...Comparison: 8/6/2018 ...IMPRESSION: Senescent skeletal changes. Negative for fracture...Moderate to large bilateral pleural effusions; left greater than right. Correlation with chest series is recommended ...."
(L) A progress note date 9/13/18 at 1256 hours indicated the following: " ...PATIENT NARRATIVE: Pt [Patient] seen and examined today. Pt is confused this am [a.m.] post fall. CT [computed tomography scan] shows new right occipital infarct. ...Pt appears to be mildly SOB [short of breath] ...Will continue to monitor closely. ...EXAM ... General: moderate cognitive impairment, pleasant, appropriate to yes and no questions. ...SKIN: ...head laceration. ...ASSESSMENT/PLAN: ...12. Fall during current hospitalization, initial encounter. P: CT head - new right occipital infarct. ...PLAN: Plan as above, continue to monitor closely ...."

A review of the "RAPID RESPONSE TEAM RECORD - FALL" dated 9/12/18 indicated the following: ...Room#/location: 552 Time called: 1535 [hours] RRT [Rapid Response Team] Arrival Time: 1535 [hours] Event End Time: 1610 [hours] ...In fall unwitnessed or head injury suspected, implement Neuro Checks Q15 minutes x [times] 4, Q30 x 2...." The medical record lacked documentation of neurological checks being completed as listed above.
A review of the "POST FALL REVIEW" dated 9/18/18 indicated the patient had a fall on 9/12/18 at 1535 hours that resulted in a one inch laceration that was cleaned and left open to air. The review lacked documentation of the location of the laceration. A CT on 9/12/18 at 5:05 p.m. indicated new right occipital lobe ischemic infarct, maturing right frontal ischemic infarct, old left occipital lobe infarct.

A review of the "Post Fall Huddle Form" dated 9/12/18 indicated the patient was attempting to use the restroom at the time of the fall, the patient was in the fall program with alarms, had cognitive issues, no skid free socks in place, no bed or w/c [wheelchair] alarm on at the time of the fall, the physician and FM #3 (family member) were notified, the Morse Fall Risk Assessment prior to fall was 85 and post fall was 95.

During an interview with NS#1 (Registered Nurse Supervisor) on 9/25/18 at 1:03 p.m., he/she indicated Patient #2 was lying face down and his/her body was in an awkward turn and the patient's whole body was on the floor. NS#1 indicated the patient had a laceration to the top of his/her head and that it was bleeding. NS#1 indicated the patient's bed alarm was not on and that he/she had not completed post fall neurological checks besides the initial neurological check right after the patient's fall, which he/she indicated was not documented.

During an interview with N#5 (Registered Nurse Supervisor) on 9/25/18 at 2:03 p.m., he/she indicated that when a fall occurs with a head injury, the standard of care is to complete neurological checks after the fall. He/she indicated the medical record of patient #2 lacked documentation of neurological checks after his/her fall on 9/12/18.

During an interview with A#3 (Chief Clinical Officer) on 9/26/18 at 2:15 p.m., he/she verified a lack of documentation of patient #2 having a bed exit alarm in use on 9/11/18 and 9/12/18 and was first documented as having a bed exit alarm in use was on 9/13/18 at 0930 hours.

During an interview with A#1 (Registered Nurse/Director of Quality) with A#8 (Vice President of Quality Risk Management) present on 9/26/18 at 2:26 p.m., A#1 indicated patient #2 was attempting to use the bathroom when he/she fell and the CT of patient #2's head after his/her fall indicated a new right occipital lobe ischemic infarct.

During an interview with NS#5 (Nurse Supervisor) on 9/26/18 at 3:52 p.m., he/she verified patient #2's medical record indicated that the bed alarm was not activated during his/her fall.

4. Review of patient #3's medical record indicated the following:
(A) The patient was an 84 year old admitted on 9/6/18 at 1942 hours. Admit diagnoses included but were not limited to acute respiratory failure secondary to traumatic head injury with subdural hematoma, subarachnoid hematoma, and parenchymal hematoma.
(B) A review of the patient's care plans indicated the following: " ...Problem 4. SAF - SAFETY - FALLS (ACTIVE) Assigned: 09/07/18. Objective: SAF - NO INJURY ...(ACTIVE) Assigned 09/07/18. Intervention: *ANTICIPATE PATIENT NEEDS (ACTIVE) Assigned: 09/07/18.
*CALL LIGHT PLACED WITHIN REACH OF PATIENT (ACTIVE) Assigned: 09/07/18.
*BED ALARM ACTIVATED WHEN PATIENT IN BED (ACTIVE) Assigned: 09/07/18.
*KEEP ALL ITEMS WITHIN PATIENTS REACH (ACTIVE) Assigned: 09/07/18.
*BED ALARM SETTINGS ARE APPROPRIATE FOR PATIENT NEEDS (ACTIVE) Assigned: 09/07/18.
*EDUCATE PATIENT IN USE OF CALL BELL (ACTIVE) Assigned: 09/07/18 ...."
(C) A "Restraint Order and Flow Record, Medical" dated 9/23/18 indicated patient #3 had a physician order signed and dated on 9/23/18 at 0815 hours for soft limb times two restraints for placement on the right and left arms. It also indicated the attending physician was notified of the restraint use and the precipitating/continued reason for the restraints was pulling at tubing/dressing, unable to follow safety instructions and to prevent disruption of life.
(D) A physician order dated 9/23/18 at 1024 hours indicated the following: " ...CT HEAD WITHOUT CONTRAST ...Start: 9/23/18 [at] 1022 [hours] Priority: ASAP [as soon as possible] Frequency: ONE TIME ...Comments: R/O [rule out] CVA ...." and was ordered by MS#4 (Physician)
(E) The "Nursing LTAC [Long-term Acute Care Hospital] Shift Assessment-Flowsheet" dated 9/6/18 at 1945 hours indicated patient #3's communication was non-verbal, nods head appropriately to yes-no questions, had generalized weakness, was dependent for activities of daily living, best verbal response was confused conversation, but able to answer questions, had a trach, peg tube for continuous enteral tube feeding, had bilateral upper extremity restraints and had a Morse Fall Risk score of 55. A fall risk level of 45 or greater equals high risk and action was to implement high risk fall precautions.
(F) The "Nursing LTAC [Long-term Acute Care Hospital] Shift Assessment-Flowsheet" dated 9/23/18 at 0700 hours indicated patient #3's communication was non-verbal, had generalized weakness, was dependent for activities of daily living, best verbal response was confused conversation, but able to answer questions, had a trach, peg tube for continuous enteral tube feeding, a indwelling Foley catheter had bilateral upper extremity restraints and had a Morse Fall Risk score of 35. A fall risk level of 25-44 equals moderate risk and action was to implement universal fall precautions.
(G) The "Patient Care Notes" dated 9/23/18 at 1715 hours indicated the following: A Registered Nurse was passing by and seen patient #3 " ...was hanging onto the bed, knees on the floor. Pt was helped back to bed by 4 staff members. Lt [left] wrist restrain [restraint] was off, rt [right] wrist restrain [restraint] was on. Foley and trach were still intact. Pt does not respond appropriately enough to explain what happened but he can answer yes or no questions appropriately. Pt was assessed and no new bruises or injuries were discovered. Pt denies pain or hitting his head on anything. ...Bed alarm did not go off and [P#8, patient care technician] said [he/she] might have disabled the bed alarm during cares and forgot to turn it back on. Dr. and family will be called."
(H) The results of CT of head without contrast indicated the following: " ...Exam Time: 09/23/2018 [at] 8:31 PM [p.m.] Reason for Exam: Cerebral infarction, unspecified (CMS/HCC) Diagnosis/Reason for Exam: Cerebrovascular accident (CVA), unspecified mechanism (CMS/HCC) Examination: CT Head Without Contrast. ...Comparison: 8/26/2018..Additional History: evaluate for CVA, fall this am, per nurse no change in status, hx [history] of L [left] temporal contusion and tentorial subdural hematoma... ...IMPRESSION: 1. No acute intracranial hemorrhage or skull fracture identified. 2. Multifocal ischemic changes appearing similar to previous. 3. Interval partial opacification of mastoid air cells. Correlate clinically for mastoiditis ...."

During an interview with NS#5 (Nurse Supervisor) on 9/26/18 at 3:52 p.m., he/she verified patient #3's medical record indicated that the bed alarm was not activated during his/her fall.

During an interview on 9/27/18 at 8:20 p.m., A#8 indicated the patients identified as high risk for falls should have a bed alarm activated.



35731

Based on document review and interview, the registered nurse failed to follow the facility policy and procedure related to fall preventions such as bed alarms being activated for three (3) of thirteen (13) medical record's (MR's) reviewed (Patient # 1, Patient # 2, Patient # 3), failed to respond to telemetry monitor alarms for one (1) of six (6) closed MR's reviewed (Patient # 1), failed to complete neurological checks after a patient fall in which an injury was sustained for one (1) of six (6) closed MR's reviewed (Patient # 2), failed to complete a post fall huddle with the staff for two (2) of thirteen (13) MR's reviewed (Patient # 1, Patient # 3), failed to ensure a telemetry monitoring strip was printed and analyzed for one (1) of six (6) closed MR's reviewed (Patient # 1), failed to ensure a critique was completed for one (1) of three (3) closed MR's reviewed for Code Blue (Patient # 1), and failed to ensure the circumstances prior to a patient's death was accurately reported to the coroner upon a patient's death for one (1) of three (3) MR's reviewed for deaths (Patient # 1).

Findings include:

1. Facility policy titled "Fall Prevention and Management Program" last reviewed/revised March 2018 indicated the following: "...POLICY: 1. All patients admitted to the inpatient setting will be assessed for fall "risk" using the Modified Morse Fall Risk on admission, each shift, change in status of the patient, and prior to patient discharge. ...4. Safety devices will be initiated when indicated according to policy as soon as possible once the patient is assessed as being "at risk" for falling. The Fall Risk Assessment will determine if there are existing "risk" factors that may affect the patient's fall risk. Interventions are designed to be implemented for patients with multiple fall risk factors and for "those who have fallen". These interventions are designed to reduce severity of injuries due to falls as well as prevent falls from reoccurring. Nursing staff/Rehabilitation staff: Consider use of safety technology for fall prevention: "Bed and chair alarms ...."

2. Facility policy titled "PLAN FOR THE PROVISION OF CARE, TREATMENT, AND SERVICES" last reviewed/revised 12/2016 indicated the following: The purpose of the plan is to provide a structure by which defined standards of patient care can be systemically organized, monitored, and evaluated. Accurate patient assessment "is a major component of patient care". These assessments continue throughout the patient's stay. A "fall risk assessment is completed along with initial assessment". Each patient is reassessed at regularly scheduled times to determine response to treatment, including when a "significant change occurs in the patient's condition" and/or when a significant change occurs in a patient's diagnosis. Care of Patients: The goal "is to provide individualized, planned, and appropriate care in a setting that supports the patient's care, treatment, therapy goals and specific needs". In the event that a patient is found to be "without a discernable pulse" and/or respirations the Code Blue process will be activated and the CPR [cardiopulmonary resuscitation] protocol will be initiated. The RN [Registered Nurse] Supervisor will perform a critique and forward to the Director of Nursing. The framework for nursing at the hospital is the nursing process. The components of the process are assessment, nursing diagnosis, planning, outcome determination, implementation, and evaluation. A registered nurse will define, direct, supervise, and evaluate the nursing care of each patient. The Telemetry Technician has been trained to read and report changes in ECG rhythms to the RN Supervisor. The Unit Secretary/Clerk assists with communication.

3. Review of the hospital policy titled, "Assessment and Reassessment", effective date 12/27/2012, indicated patients at the hospital receive care "based upon a documented assessment of patient care needs and problem identification". The plan of care "is a system for defining care goals for each patient based on the assessment process". This policy was last revised on 12/2016.

4. Review of the hospital policy titled, "Guidelines for Nursing Care", effective date 10/2010, indicated to ensure quality patient care, certain standards of care must be upheld. The following "basic nursing task" designates the minimum frequency with which the task must be performed to maintain quality of care: "telemetry alarms" should be "on at all times" with parameters individualized per patient "every shift". This policy was last revised on 12/2016.

5. Review of the hospital policy titled, "Telemetry Admission and Discharge Criteria", effective date 07/2011, indicated a "cardiac monitor will be placed on a patient at the request and/or order of the physician". A six (6) second rhythm strip should be recorded every shift for medical/surgical patients should be documented in the nurses' notes. This policy was last reviewed on 10/2017.

6. Review of the hospital policy titled, "Death-Notification of Coroner...", effective date 10/01/2013, indicated the coroner must be notified upon every death. A physician and surgeon, or other person shall immediately notify the coroner when he/she has knowledge of a death which "occurred under any of the following circumstances:...(e) Following an injury or accident..." The "Duty of Coroner to Investigate Violent, Sudden, Unusual, Etc., Deaths". It shall be the "duty of the coroner to inquire into and determine the circumstances" ...deaths known or suspected as resulting in whole or in part from or related to accident or injury either old or recent..." This policy was last revised on 02/2017.

7. Review of the signed "Job Description and Competencies-Telemetry Monitor Tech" for P # 4 (Telemetry Monitor Tech) dated 06/25/2018, indicated eighty percent (80%) of the job function was to "continually observe and analyze telemetry monitors and immediately report significant changes in rhythms to the appropriate personnel". The following core competency was completed on 09/05/2017: "continuously monitors telemetry of patients-recognizes basic lethal rhythms" and "immediately reports yellow and red alarms to nursing". The 2018 annual education fair held for monitor techs dated 05/16/2018, indicated "Skill/Knowledge/Competency" for critical care station-"Clinical Alarms Competency" and "Telemetry Rhythm Interpretation Test".

8. Review of the signed "Job Description and Competencies-Unit Secretary/Unit Clerk" for P # 5 (Unit Secretary/Unit Clerk) dated 12/19/2017, indicated the position was responsible for directing the orderly flow of the unit and patient related data. Responsible for "communications through the answering and initiation of telephone calls..."

Patient # 1:

1. Review of patient # 1's MR indicated the following:
A. The patient was a 79 y/o (year/old) admitted from H # 3 (Acute Care Hospital) to H # 1 (Long Term Care) Hospital on 08/23/2018 at 7:10 pm.
B. The Pre-Admission Assessment Form completed on 08//23/2018 at approximately 4:17 pm by CL # 1 (Clinical Liaison), indicated the patient to be alert and orientated times three (3). The patient had been intubated on 08/05/2018 and was wearing a tracheostomy collar with a # 8 shiley uncuffed tracheostomy tube. The patient's treatment plan included the following precautions: safety, aspiration, bed alarm and fall. The patient also required the following specialty equipment: LAL (low air loss) mattress, feeding pump, intravenous (IV) pump and the "other" box was checked with telemetry indicated. The patient was documented as a moderate assist.
C. Review of the Ventilation/Complex Respiratory Admission Guidelines form indicated the services that were to be provided were reasonable and necessary for the patient. "Continuous cardiac monitoring" was indicated as treatment needed.
D. The patient's diagnoses included, but were not limited to, acute and chronic respiratory failure, COPD (Chronic Obstructive Pulmonary Disease) exacerbation, acute and chronic diastolic CHF (Congestive Heart Failure), anemia, hypertension, hypothyroidism, debility, reactive depression, Alzheimer's dementia without behavioral disturbance.
E. Review of the Patient Care Notes dated 08/28/2018 by NS # 7 (RN) at approximately 2:00 am, indicated the "bed alarm on" due to while sitting in room charting "looked over" and "patient was sitting on the side of the bed". The patient was assisted to a lying position and instructed as to why he/she can "NOT JUST GET UP".
F. Review of the Patient Care Notes dated 09/08/2018 by NS # 3 at approximately 8:00 pm, indicated the patient had an unwitnessed fall. The patient was observed by a PCT (patient care tech) to be sitting up against the bed with non-skid socks on. Patient was assisted to bed and the bed alarm was turned on.
G. Review of the Patient Care Notes dated 09/11/2018 by NS # 4 (RN) at approximately 12:02 am, indicated the patient was "found slumpt over side of bed blocking tracheal opening". The patient was placed back in bed and "found to be pulseless and in asystole".
H. The Initial Care Plan dated 08/23/2018 lacked "safety-falls" interventions and "artificial airway" interventions. The Care Plan was updated on 09/13/2018 which included, but were not limited to, the problems "Safety/Falls and "Artificial Airway". The interventions included "bed alarm settings are appropriate for patient needs, bed alarm activated when patient in bed", and the objective for RT (respiratory therapy) was to "protect and secure" the airway and to "maintain" a "patent airway".
I. Review of the Care Plan for patient # 1, indicated the plan lacked any documentation related to interventions for telemetry monitoring throughout the patient's admission.
J. The MR lacked any documentation related to telemetry monitoring strips for the night shift on 09/11/2018.

2. Review of the "Post Fall Review" dated 09/10/2018 (no documented time), by A # 1 (Director of Quality), indicated patient # 1 had an unwitnessed fall on 09/08/2018 at approximately 8:00 pm. "No action indicated" was checked. The "Post Fall Huddle" dated 09/08/2018 at approximately 11:00 pm by NS # 3 (RN Supervisor), indicated the recommendation was to "have bed alarm on".

3. Review of the "Post Fall Review" dated 09/12/2018 (no time documented), by A # 1, indicated patient # 1 was found at 12:02 am "on knees facing the bed at the left side of the foot of the bed by the nursing supervisor" and a "code" was called. The action "Physician Review Required" was checked and indicated completed by MS # 3 (Physician) "via phone" on 09/17/2018. An RCA (Root Cause Analysis) was documented as completed but unavailable to this writer to review per A # 1.

4. In interview on 09/24/2018 at approximately 2:20 pm by A # 1, confirmed a "Post Fall Huddle" should have been completed for patient # 1 after the fall on 09/12/2018.

5. In interview on 09/24/2018 at approximately 3:10 pm by A # 4 (Nurse Manager), confirmed he/she had terminated the telemetry monitor tech (P # 4), and unit secretary/clerk (P # 5) after the incident which occurred on 09/12/2018 with patient # 1. The "teletech monitor tech called the unit clerk" to tell them the patient was "off the heart monitor". The unit clerk "did not tell anyone" and P # 5 "should have". Thirty (30) minutes later the telemetry monitor tech "called back" to say the patient was "still of the monitor" and at that time the RT (Respiratory Therapy) answered the phone. The "teletech should have followed up quicker than that". The "RT said something to the Charge Nurse who went in the room" with two (2) PCT's (Patient Care Tech's) and "found the patient hanging on the bed", pulseless and the "trach was out" on the bed, obviously the patient had no oxygen on. At that time a "Code Blue" was called.

6. In interview on 09/24/2018 at approximately 4:35 pm by A # 4, confirmed that NS # 4 (Registered Nurse) had assisted patient # 1 to their BSC (bed side commode) and when NS # 4 assisted the patient "back to bed" he/she "didn't put the bed alarm on and should have".

7. In interview on 09/24/2018 at approximately 5:00 pm by A # 4, confirmed the NS # 4 "teletech did not do any" heart monitor "strips at all that night" for patient # 1. It was indicated that this was discovered during the investigation process.

8. In interview on 09/25/2018 at approximately 10:00 am by A # 1, confirmed "no MD [Medical Doctor] review was documented/completed", and an "MD should have reviewed this case" for patient # 1 post incident on 09/12/2018.

9. In interview on 09/26/2018 at approximately 3:55 pm by NS # 4 who had been assigned to care for patient # 1 on 09/11/2018 night shift, confirmed he/she "forgot to turn the bed alarm on".

10. In interview on 09/27/2018 at approximately 11:20 am by A # 5 (Human Resource Manager), confirmed the telemetry monitor technicians would report to the nurse supervisor.

11. In interview on 09/27/2018 at approximately 1:20 pm by NS # 1 (Nurse Supervisor), confirmed he/she did "not say anything to the coroner about the patient being coded and being placed on the vent" (ventilator).

12. In interview on 09/27/2018 at approximately 2:00 pm with administrative staff member A # 3 (Chief Clinical Officer-CCO), confirmed speaking to NS # 6 (Nurse Supervisor) via telephone related to the "Code Blue Critique" for patient # 1 which had occurred on 09/12/2018. A # 3 confirmed that NS # 6 indicated he/she "forgot to do the evaluation".

13. In interview on 09/27/2018 at approximately 2:05 pm with administrative staff member A # 10 (Senior Vice President (VP) Clinical Operations), confirmed that patient # 1 had not been placed on "adequate interventions" prior to the date of 09/13/2018 for "safety/falls, telemetry monitoring and tracheostomy care". There "is a problem".

14. In interview on 09/27/2018 at approximately 3:50 pm with NS # 5 (Nurse Supervisor), confirmed the "coroner should have been notified" that patient # 1 was "coded after being found unresponsive" and then "placed on a vent". We "have been trained" on the proper way to do it.

Patient # 2:

1. Review of patient #2's medical record indicated the following:
(A) The patient was a 68 year old admitted on 8/23/18 at 1800 hours. Admit diagnoses included but were not limited to acute on chronic systolic congestive heart failure and cerebrovascular accident.
(B) A review of the patient's care plans indicated the following: " ...Problem 3. SAF - SAFETY - FALLS (ACTIVE) Assigned: 8/25/18. Objective: SAF - NO INJURY ...(ACTIVE) Assigned

Based on document review and interview, the facility failed to ensure the nursing staff followed the policy and procedure related to developing and updating the patients plan of care (treatment plan) for one (1) of six (6) patient closed medical records (MR's) reviewed (Patient # 1).

Findings include:

1. Review of the hospital policy titled, "Care Planning", effective date 10/2007, indicated the "Case Managers will establish a written Plan of Care for each patient which will include a detailed treatment plan". The "plan will be updated as required by regulation or with patient need changes". This policy was last revised on 01/2015.

2. Review of the hospital policy titled, "Plan for Provision of Care", effective date 04/2007, indicated the "purpose of the plan is to provide a structure by which defined standards of patient care can be systematically organized, monitored, and evaluated". The goal "is to provide individualized, planned, and appropriate care in a setting that supports the patient's care, treatment, therapy goals and specific needs". A registered nurse (RN) will "define, direct, supervise, and evaluate the nursing care of each patient". Basic nursing clinical activities are delivered as and a plan of care should be "developed within twenty-four (24) hours of admission" from data collected during assessment and in conjunction with the physician, patient and family. The "Plan of Care is updated as patient needs change". Major interventions by nursing personnel included, but were not limited to "cardiac monitoring and respiratory care". A "fall risk assessment" should be completed along with the "initial assessment". This policy was last reviewed on 12/2016.

3. Review of the hospital policy titled, "Assessment and Reassessment", effective date 12/27/2012, indicated patients at the hospital receive care "based upon a documented assessment of patient care needs and problem identification". The plan of care "is a system for defining care goals for each patient based on the assessment process". This policy was last revised on 12/2016.

4. Review of the "Post Fall Review" dated 09/10/2018 (no time documented), by A # 1 (Director of Quality), indicated patient # 1 had an unwitnessed fall on 09/08/2018 at approximately 8:00 pm. "No action indicated" was checked. The "Post Fall Huddle" dated 09/08/2018 at approximately 11:00 pm by NS # 3 (RN Supervisor), indicated the recommendation was to "have bed alarm on".

5. Review of the "Post Fall Review" dated 09/12/2018 (no time documented), by A # 1, indicated patient # 1 was found at 12:02 am "on knees facing the bed at the left side of the foot of the bed by the nursing supervisor" and a "code" was called. The action "Physician Review Required" was checked and indicated completed by MS # 3 (Physician) "via phone" on 09/17/2018. An RCA (Root Cause Analysis) was documented as completed but unavailable to this writer to review per A # 1.

6. Review of the closed MR for patient # 1 indicated the following:
A. The patient was a 79 y/o (year/old) admitted from H # 3 (Acute Care Hospital) to H # 1 (Long Term Care) Hospital on 08/23/2018 at 7:10 pm.
B. The Initial Care Plan dated 08/23/2018 lacked "safety-falls" interventions and "artificial airway" interventions. The Care Plan was updated on 09/13/2018 which included, but were not limited to, the problems "Safety/Falls and "Artificial Airway". The interventions included "bed alarm settings are appropriate for patient needs, bed alarm activated when patient in bed", and the objective for RT (respiratory therapy) was to "protect and secure" the airway and to "maintain" a "patent airway".
C. Review of the Patient Care Notes dated 08/28/2018 by NS # 7 (RN) at approximately 2:00 am, indicated the "bed alarm on" due to while sitting in room charting "looked over" and "patient was sitting on the side of the bed". The patient was assisted to a lying position and instructed as to why he/she can "NOT JUST GET UP".
D. Review of the Patient Care Notes dated 09/08/2018 by NS # 3 at approximately 8:00 pm, indicated the patient had an unwitnessed fall. The patient was observed by a PCT (patient care tech) to be sitting up against the bed with non-skid socks on. Patient was assisted to bed and the bed alarm was turned on.
E. Review of the Patient Care Notes dated 09/11/2018 by NS # 4 (RN) at approximately 12:02 am, indicated the patient was "found slumpt over side of bed blocking tracheal opening". The patient was placed back in bed and "found to be pulseless and in asystole".
F. Review of the Care Plan for patient # 1, indicated the plan lacked any documentation related to interventions for telemetry monitoring throughout the patient's admission.

7. In interview on 09/27/2018 at approximately 2:05 pm with administrative staff member A # 10 (Senior Vice President (VP) Clinical Operations), confirmed that patient # 1 had not been placed on "adequate interventions" prior to the date of 09/13/2018 for "safety/falls, telemetry monitoring and tracheostomy care". There "is a problem".

Based on document review and interview, the facility failed to ensure the patient's medical record (MR) was accurately written and promptly completed for two (2) of six (6) closed patient MR's reviewed. (Patient # 1 and Patient # 7)

Findings include:

1. Review of the hospital policy titled "Medical Record Documentation Requirements", effective date 11/2010, indicated "all medical records will contain documentation to substantiate care and treatment provided". This policy was last revised on 12/2016.

2. Review of the hospital policy titled "Mechanical Ventilation-Terminal Wean", effective date 11/2007, indicated when it has been determined that a ventilator-dependant patient's care has become futile and the physician and the family have agreed to not pursue further aggressive treatment and allow a natural death, "a terminal wean may be initiated upon physician order". This policy was last revised 05/2016.

3. Review of the "Medical Staff Bylaws", indicated on page nineteen (19) 2.6 the basic responsibilities of medical staff membership..."2.6-8 Prepare and complete, in a timely and accurate manner, the medical and other required records for all patients to who the Practitioner in any way provides services in the Hospital, including compliance with such electonic health record (EHR) policies and protocols as have been implemented by the Hospital".

4. On 09/27/2018 at approximately 2:10 pm with administrative staff member A # 3 (Chief Clinical Officer-CCO), the MR for patient # 7 was reviewed. The MR lacked a physician order for the patient to be transferred to the Emergency Department (ED) for evaluation and treatment on 09/04/2018.

5. On 09/27/2018 at approximately 2:45 pm with administrative staff member A # 3, the MR for patient # 1 was reviewed. The MR lacked physician orders for patient # 1 to be monitored on telemetry (had telemetry strips in MR), and to be terminal weaned off the vent. The patient care progress notes indicated the terminal wean process was imitated on 09/14/2018 at approximately 12:58 pm by NS # 5 (Nursing Supervisor). The patient expired on 09/15/2018 at 1:04 pm.

6. In interview on 09/26/2018 at approximately 2:10 pm with administrative staff member A # 3, confirmed the MR lacked the physician order for the patient to be transferred to the ED on 09/04/2018.

7. In interview on 09/27/2018 at approximately 2:45 pm with administrative staff member A # 3, confirmed the MR for patient # 1 lacked a physician order for the patient to be a "terminal wean" and at approximately 3:30 pm confirmed the MR for patient # 1 lacked a physician order for the patient to be monitored on telemetry during his/her admission.

8. In interview on 09/27/2018 at approximately 2:50 pm with administrative staff member A # 10 (Senior Vice President Clinical Operations), confirmed the "physician should have written the orders".