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Based upon reviews of hospital policies and procedures related to transportation of patients, 1 of 4 medical records (patient #4), staff and Administrative interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by allowing only one Mental Health Technician, who was also drove the hospital van, to transport patient #4 to an acute care hospital for evaluation after the patient experienced low blood pressure. Findings:

Review of the hospital's policies and procedures for transportation of patients revealed a lack of documented evidence the hospital had formulated and implemented a policy/procedure for the use of the hospital's transport van to be used for the transportation of medically acute patients. There failed to be documentation relative to the number and type of qualified hospital personnel who would accompany patients during transport, via the hospital's transport van, to other facilities.

Review of patient #4's medical record revealed the patient was admitted to the hospital on 03/09/10 with the diagnoses of "Other Persistent Mental Disorder" and "Anxiety Disorder" and for adjustment of her psychotropic medications. According to the nursing notes, dated 03/27/10, 6:30 AM, Registered Nurse (RN) S7, documented the patient was found to be drowsy and her skin was moist. RN S7 obtained a blood glucose by finger stick which was 178, and documented the patient's vital signs as blood pressure 100/60, pulse 92, respirations 24, and temperature 97.3. Further review of the nursing notes dated 03/27/10, 7:30 AM, revealed during RN S3's initial nursing shift assessment of the patient revealed the patients blood pressure had dropped to 78/40. The Advanced Practice Registered Nurse (APRN), S9, who was the on-call medical provider, was notified of the patient's low blood pressure and lethargy. APRN S9 instructed RN S3 if patient #4 could be aroused, she could send the patient, by the hospital's van, to Hospital A for evaluation. If the patient could not be aroused, RN S3 was to call emergency services to transport the patient by ambulance. The patient was transferred to Hospital A at 8:10 AM by the hospital's transport van.

Interview, 05/04/10, with Registered Nurse (RN) S3 revealed while making her nursing rounds, on 03/27/10, after the change of shift nursing report, she noticed patient #4 "did not look good", her skin was moist and the patient appeared drowsy. During her assessment of patient #4, RN S3 stated when she obtained the patient's blood pressure it was 78/40. She notified the APRN S9 of the patients low blood pressure who instructed her to go ahead and send the patient to Hospital A for evaluation. RN S3 was questioned as to who made the decision to send patient #4 on the hospital's transport van instead of telephoning for an ambulance; she replied, "APRN S9 instructed me that if the patient was alert and could walk and talk it would be ok if the transport van took her to the hospital; but if patient #4 needed to be sent by ambulance to call them." RN S3 stated patient #4 was alert, did not complain of pain, could walk and talk so she was sent by the transport van. Further questioning of RN S3 revealed one Mental Health Technician (MHT), S8, accompanied patient #4 to acute care Hospital A. RN S3 was asked if there was any other hospital personnel with MHT S8 and patient #4; she replied, it was just MHT S8 and the patient. There failed to be documented evidence patient #4 had her blood pressure monitored during transportation to the acute care hospital (Hospital A).

Interviews, on 05/04/10, with hospital Administrator S1 and Director of Nursing (DON) S2 confirmed the hospital did not have a policy/procedure that addressed the number and qualifications of hospital personnel who were to accompany patients during transport, via the hospital's transportation van, to other facilities. Upon further questioning, Administrator S1 and DON S2 both confirmed there should have been another hospital employee sent with patient #4 and MHT S8 to ensure patient #4's safety by the monitoring of the patients blood pressure and monitoring her for any increased anxiety related to her psychiatric diagnoses.

Based upon review of 1 of 4 medical records (#4), hospital policies and procedures, and administrative staff interviews, the hospital failed to ensure the Registered Nurse kept current patient #4's plan of care as evidenced by failing to update the nursing care plan and document nursing interventions after patient #4 had two falls. Findings:

Review of patient #4's medical record revealed on 03/20/10, 2:00 PM, while the patient was ambulating in the Dining Room with a walker her legs became weak, she fell to the floor. On 03/22/10, 11:30 PM, the Mental Health Technician found the patient lying on the floor at the side of the bed. Review of the Multidisciplinary Integrated Treatment Plan revealed upon admission to the hospital on 03/09/10, the Registered Nurse assessed the patient as being at a high risk for falls related to "Effects in mobility or sensorium secondary to medication regimen" as evidenced by "Poor judgement and impulse". The goals were identified as "Patient will remain free of falls by discharge within 14 days" with Objectives as "Patient will verbalize need to request assistance as needed to prevent fall within 14 days" and "Monitor for fall risk during medication adjustments". The nursing clinical interventions were 1) Initiate Fall Assessment protocols per guidelines, 2) Reassess fall risk weekly and as needed, 3) Identify fall risk on treatment plan, 4) patient observation every 15 minutes or greater if needed, 5) Assess patient's knowledge and cognition and teach fall prevention and safety measures according to patient's ability to learn and practice these measures daily and PRN (as needed), 6) Provide safe environment by identifying fall inducing hazards and keeping patient's environment clear of these hazards daily. There was no identification of adaptive equipment that was to be used.

Further review of patient #4's medical record revealed on 03/27/10, 6:30 AM, Registered Nurse (RN) S7 documented "Due to fall precautions, mattress was placed on floor near bed...". Review of the fall interventions on the Multidisciplinary Integrated Treatment Plan revealed the RN failed to update the plan and identify placing a mattress on the bed to prevent patient injury from falls.

Review of policy TX-Gen-02: Treatment Planning; Integrated/Multidisciplinary, adopted March 2008, revealed "...The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care." Nursing responsibilities included "Revises and develops nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician orders."

Review of policy #AS-12: Fall Assessment/Re-Assessment and Precautions, adopted in March 2008, revealed "All patients will be assessed and identified for the potential of being at risk for falls upon admission and every 7 days if identified as moderate or high risk. In the event of a fall occurrence, patients will be re-assessed every day and secondary prevention Falls prevention strategies instituted. The RN utilizing the Fall Risk criteria score sheet, will assess/re-assess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated." For Re-Assessment after a fall, the Charge RN/Primary RN was to "Re-assess fall risk every day, Institute Secondary Fall Prevention strategies and update Fall Treatment Plan, Secure MD permission for additional precautions to include 1:1 in special cases..." Guidelines for Patient Safety were identified as "Patient Bed/Room Measures: Keep bed in low position, Keep bed in locked position, Use bed alarms as appropriate, Provide bell at bedside, Leave bathroom light on". Ambulation Safety Measures were to include "Eliminate environmental hazards (remove wastebaskets, other items from the path between patient's bed and doorway), Instruct patient to wear shoes with non-skid soles, Instruct patient to ask for assistance if feeling weak, dizzy, or light-headed, Instruct patient to notify staff of any spills, Offer frequent toileting, Attempt to relocate patient near nurses' station as appropriate (for fall or repeat fall)."

Interview on 05/04/10, 10:30 AM, with the Hospital Administrator S1 and the Director of Nursing S2 revealed when asked about the Secondary Fall Prevention strategies identified in policy AS-12, they responded those strategies were the Patient Bed/Room Measures and the Ambulation Safety Measures. When asked about placing the mattress on the floor next to patient #4's beds, S1 and S2 replied this was also an intervention for patient safety.

The Registered Nurse failed to follow hospital policy and procedure and update patient #4's nursing plan of care after the patient sustained a fall on 03/20/10 and 03/22/10. According to policy AS-12, if a patient fall occurred, the patient was to be re-assessed every day and secondary fall prevention strategies instituted. Policy TX-Gen-02 identified the nurse was to revise the nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations. Review of patient #4's Multidisciplinary Treatment Plan revealed for the "Problem" category, "Fall during hospital stay (Requires change in treatment plan, Indicate change)" failed to be identified. The patient's risk for falls was identified on admission 03/09/10. The "Date Expected to Achieve" was initially identified for 03/23/10 and then extended to 03/30/10. RN S3 documented the "Date Actually Achieved" as 03/27/10, the date the patient was discharged from the hospital and transferred to acute care Hospital A. There failed to be documented evidence the RN updated the treatment plan after patient #4 sustained two falls.