HospitalInspections.org

Based on record review and interviews, the hospital failed to ensure the patient or his or her representative had the right to make informed decisions regarding his or her care. This was evidenced by:
1) failure to have signed consents for treatment and patient rights for 1 (#1) of 6 (#1-#6) patients reviewed for signed consents upon hospital admission; and
2) failure to have signed consents to transfer patient prior to leaving the hospital for higher level of care for 3 (#1, #2 & #4) of 3 (#1, #2 & #4) patients reviewed for signed transfer consents.
Findings:

Review of the hospital's policy number RTS-11 titled "Informed Consent, Care Decisions, and Conflicts Resolutions" last revised on 11/01/2024 revealed in part:
"Purpose: To outline the responsibility of the facility in establishing a mutual understanding between the patient/patient's family/representative and the facility about patient services received. To involve patients and significant others, when appropriate, in care decisions, conflict resolution, and the informed consent process.
Policy: The facility recognizes the benefit and the need to involve patients and significant others, when appropriate, in care, treatment and service decisions, conflict resolution, and to ensure that appropriate informed consent is obtained as outlined by the State, Federal and other regulatory bodies.
Procedure: Informed Consent -
2. The facility will ensure that during the admission process and at any point, as necessary, in the patient's stay each patient/patient's family, if indicated will receive the following:
- Explanation of care, services and treatment being offered.
- Discussion of reasonable alternatives and the risks, benefits and side effects to such care.
- Explanation of the relevant risks, potential benefits, and side effects of proposed care, including the possible results of not receiving care, treatment, and services.
3. The facility will, during the admission process, obtain signature on informed consent forms. Patient signatures may be obtained by handwritten signature or digitized signature which is an electronic image of an individual's handwritten signature reproduced using a signature pad. If the patient is unable to sign due to physical impairments, verbal consent can be obtained and documented with two witnesses. In the case of involuntary admission, the facility will follow the policies of the organization related to involuntary admission."

Review of the hospital's policy number NSG-24 titled "Transfer of a Patient to an Acute Care Facility" last revised on 10/01/2024, revealed in part:
"Purpose: To maintain the continuity of patient care by communicating to the receiving facility with appropriate information. To comply with regulatory guidelines regarding patient transfer.
Policy: If the Hospital is unable to adequately meet a patient's needed, a physician may order a transfer to a more appropriate facility. It is a patient's right to request transfer to another facility. Appropriate transfer and referrals are made if this facility cannot meet a patient's needs and keeping the patient may jeopardize their well-being. This policy applies to patients transferred to another psychiatric hospital or short-term acute care facility."

1) Failure to have signed consents for treatment and patient rights for 1 (#2) of 6 (#1-#6) patients reviewed for signed consents upon hospital admission.

Review of Patient #2's medical record revealed she was admitted to the hospital on 01/14/2025 at 8:30 PM from an outside referring hospital's emergency department for Psychosis Aggression with secondary diagnoses of Mild Mental Retardation with an I.Q. of 50-70; Bipolar Type 1 Disorder; Dementia with Mood Disturbances; and Oppositional Defiant Disorder.

Review of Patient #2's admission packet revealed no signed consent for treatment or review of patient rights. There was also no documentation by staff Patient #2 had refused to sign or was unable to sign at the time of her admission.

On 03/05/2025 at 1:45 PM, an interview was conducted with S5QA during patient chart review. She confirmed Patient #2 did not have a signed consent for treatment or review of patient rights in her chart along with no staff documentation Patient #2 had refused to sign or was unable to sign at the time of her admission. She further confirmed Patient #2 should have had these signed consents or staff documentation in their place.

2) Failure to have signed consents to transfer patient prior to leaving the hospital for higher level of care for 3 (#1, #2 & #4) of 3 (#1, #2 & #4) patients reviewed for signed transfer consents.

Patient #1
Review of Patient #1's medical record revealed she was admitted to the hospital on 12/10/2024 at 7:45 PM from an outside referring hospital's emergency department for dementia with behavioral disturbances.

Review of Patient #1's consents revealed staff documentation on 12/10/2024 at 8:04 PM of "Patient Refused" to sign consent for treatment which included the consent to transfer for the duration of her admission to the facility. No additional consents for transfers were found in her chart.

Review of Patient #1's Physician's Orders for December 2024 revealed in part:
12/14/2024 Transfer patient to local hospital emergency department s/p unwitnessed fall
12/15/2024 Transfer patient to local hospital emergency department s/p unwitnessed fall
12/17/2024 Transfer now for fall
12/18/2024 Transfer now Patient #1 had stitches seemingly break open

Review of Patient #1's Nursing and Medical Progress Notes dated 12/14/2024, 12/15/2024, 12/17/2024, and 12/18/2024 revealed no documentation of discussion with Patient #1 and/or representative of the need for being transferred, risk vs. benefits of being transferred and the possible outcome if not being transferred to a higher level of care for evaluation and possible treatment following a fall with head injury. Nurse documentation did reveal notification to representative of the transfer however.

Patient #2
Review of Patient #2's medical record revealed she was admitted to the hospital on 01/14/2025 at 8:30 PM from an outside referring hospital's emergency department for Psychosis Aggression with secondary diagnoses of Mild Mental Retardation with an I.Q. of 50-70; Bipolar Type 1 Disorder; Dementia with Mood Disturbances; and Oppositional Defiant Disorder.

Review of Patient #2's consents revealed no signed consent for transfer to another facility. There was also no documentation by staff Patient #2 had refused to sign or was unable to sign at the time of her admission.

Review of Patient #2's Physician's Orders for January 2025 revealed in part:
01/15/2025 Transfer patient to local hospital's emergency room due to fall
01/20/2025 Patient transferred to local hospital's emergency room due to decreased level of consciousness and possible aspiration

Review of Patient #2's Nursing and Medical Progress Notes dated 01/20/2025 revealed no documentation of discussion with Patient #2 and/or representative of the need for being transferred, risk vs. benefits of being transferred and the possible outcome if not being transferred to a higher level of care for evaluation and possible treatment following a fall with head injury.

Patient #4
Review of Patient #4's medical record revealed he was admitted to the hospital on 02/13/2025 at 8:15 PM from an outside referring hospital's emergency department for Suicidal Ideations and Dementia.

Review of Patient #4's consents revealed he signed his consent for treatment, which included consent for transfer upon admission to the facility on 02/14/2025, but no time was documented. No additional consents for transfer were found in his chart.

Review of Patient #4's Nursing Note dated 02/14/2025 at 6:51 AM revealed "Notified S6NP to transfer to ER for evaluation." Further review revealed nurse notified family member of incident and transfer to local hospital emergency department, however no documentation of discussion with Patient #4 and/or representative of the need for being transferred, risk vs. benefits of being transferred and the possible outcome if not being transferred to a higher level of care for evaluation and possible treatment following a fall with head injury was found.

On 03/03/2025 at 11:51 AM, an interview was conducted with S1QD. She stated the consent for transfer was completed during the admission process to the facility, and no additional transfer consents were completed during a patient's hospitalization if they were to require transfer to an outside acute care facility for further evaluation and/or additional treatment. She stated all transfers are considered emergent in nature which is why the patient is being transferred to a higher level of care.

Based on record review and interviews, the hospital failed to ensure initial reports of allegations of patient abuse/neglect of care were reported to Louisiana Department of Health within 24 hours of awareness of the allegation, as required by LDH-HSS, for 2 (#1 & #4) of 3 (#1, #2, & #4) patients reviewed for falls with injury requiring transfer to an outside facility for further evaluation and treatment.
Findings:

Review of the State law R.S. 40:2009.20 revealed "Any person who is engaged in the practice of medicine, social service, facility administration, psychological services or any RN, LPN, nurses' aide, personal care attendant, respite worker, physician's assistant, physical therapist, or any other healthcare giver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within 24 hours, submit a report to the department or local law enforcement agency of such abuse or neglect."

Review of the hospital's Self-Report Log for December 2024 to March 2025 revealed no self-reports for any patients with falls with injury requiring transfer to an outside facility for further evaluation and/or treatment and specifically did not reveal any reports for Patients #1 or #4.

Patient #1
Review of the hospital's Incident Reports revealed the following:
On 12/15/2024 at 3:10 AM, Patient #1 sustained an unwitnessed fall in the common area which resulted in a laceration to the right side of her scalp with a hematoma and a hematoma and bruising to her right shoulder. Patient #1 was transferred by ambulance to outside facility for emergent evaluation and treatment.

Review of Patient #1's discharge paperwork dated 12/16/2024 from the outside facility she was transferred to for evaluation and subsequently admitted to the ICU for treatment of a traumatic subdural hemorrhage without loss of consciousness, a broken right clavicle bone and multiple bruises and contusions on her upper left and right extremities, right shoulder and right temporal/frontal scalp area with a laceration. Patient #1 was discharged and returned to this hospital via local ambulance transport on 12/16/2024 in stable condition.

Patient #4
Review of the hospital's Incident Reports revealed the following:
On 02/14/2025 at 5:55 AM, Patient #4 sustained an unwitnessed fall in his room which resulted in an approximately 4 cm in length laceration to the middle of Patient #4's forehead. Patient #4 was immediately transferred by ambulance to an outside facility for emergent evaluation and treatment.

Review of Patient #4's discharge paperwork dated 02/25/2025 from the outside facility he was transferred to for evaluation and subsequently admitted to for surgical intervention for placement of an odontoid screw for the treatment of a C2 odontoid fracture as a result of the fall. Patient #4 did not return to this hospital.

On 03/05/2025 at 3:00 PM, an interview was conducted with S1QD. She stated both Patients #1 and #4 sustained injuries related to their falls while admitted. She stated it was not hospital practice to report falls with injury to LDH-HSS, however both incidents had internal RCA investigations ongoing. S1QD confirmed both Patient #1 and #4's falls were unwitnessed which resulted in head injuries.

Based on record review and interview the facility failed to thoroughly analyze all adverse patient events and implement preventive actions. The deficient practice is evidenced by:
1) failure to accurately complete fall assessments upon admission to the hospital and post fall reassessments for 6 (#1-#6) of 6 (#1-#6) patients evaluated for admission and post fall (re)assessments; and
2) failure to re-educate staff on implementation of preventive measures and documentation of the use of those measures for each patient on fall precautions.
Findings:

Review of the hospital's policy number AS-12 titled Fall Assessment/Re-Assessment and Precautions, last revised on 11/16/2022 revealed in part:
"Purpose: To screen patient's potential for falling and decrease the risk of injury.
Policy: Inpatient
1. All patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the time of their initial nursing assessment, immediately after a fall, or change in mobility status, and/or every 7 days if identified as "at risk for falls".
2. In the event of a fall occurrence, patients will be re-assessed and additional fall prevention interventions will be implemented.
3. The Registered Nurse (RN) utilizing the Fall Risk criteria on the Fall Risk Assessment Tool will assess/re-assess and determine the risk of all patients with regard to falls and implement fall precautions if so indicated.
Procedure: Inpatient
1. The admitting RN shall complete an initial assessment within 8 hours of patient's admission, evaluates patient's ambulatory status and completes Fall Risk criteria. If a Fall Risk Score indicates the patient is "at risk for falls," the immediate initiation of fall precautions will occur.
2. If a patient scores as "at risk for falls" during the initial nursing assessment, a Treatment Plan to address the risk for falls will be initiated by the RN.
3. Criteria may be used to determine fall risk:
-Age; Mental Status; Elimination; Medications; Diagnoses; Ambulation/Balance/Mobility Devices/Use of Assistive Devices; Nutrition; Sleep Disturbances; History of falls
4. The patient shall be re-assessed by the RN for fall risk at a minimum of every 7 days, immediately after a fall, and as needed based on patient's condition.
5. Interventions shall include:
-Mandatory fall precautions - Interventions for "at risk for falls" (must implement ALL):
*Apply yellow fall risk arm band
*Provide nonskid slipper socks or ensure appropriate skid-proof footwear is used
*Provide patient education
*Initiate Fall Risk treatment plan
-Additional fall precautions - (must select at least 2 additional interventions from list that are appropriate to the patient's individual needs):
*Bed alarm
*Chair alarm
*Ambulate with staff assistance
*Ensure assistive devices (ex: eyeglasses, hearing aids) are available
*Keep pathways clear
*Line of Sight observation level
*1:1 observation level
*Reclining Chair
*Assist with ADL's
6. Post fall interventions shall include:
-RN physical assessment of the patient; Obtain vital signs including pain assessment; Initiate neurological assessment if fall was unwitnessed or if fall resulted in head injury; Notify Physician/Non-physician practitioner (NPP) and ER orders as needed; Conduct a re-assessment of fall risk using the fall risk tool; Implement secondary fall prevention interventions from the additional precautions interventions list and update Fall Risk related Treatment Plan with individualized interventions; Complete Post-Fall Checklist
7. General Guidelines for Patient Safety:
-Patient Bed/Room Measures: Keep bed in low position; Keep bed in locked position; Use bed alarms/chair alarms as appropriate; Provide bell at bedside; Leave bathroom light on; Use manufacturer low bed whenever possible.
-Ambulation Safety Measures: Eliminate environmental hazards (remove wastebaskets, other items from the path between patient's bed & doorways); Instruct patient to wear shoes with non-skid soles or provide patient with non-skid footwear; 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); Keep ambulatory devices (walker, cane, wheelchair) within reach; Provide appropriate ROM exercises to include balancing and strengthening.
8. An incident report will be completed in its entirety and forwarded to the DON after every fall.

1) Failure to accurately complete fall assessments upon admission to the hospital and post fall reassessments for 6 (#1-#6) of 6 (#1-#6) patients evaluated for admission and post fall (re)assessments.

Patient #1
Review of Patient #1's medical record revealed she was admitted to the hospital on 12/10/2024 at 7:45 PM from an outside referring facility's emergency department for Dementia with Behavioral Disturbances.

Review of Patient #1's Incident Reports revealed in part:
Date/Time: 12/14/2024 at 7:10 PM
Incident Type: Multiple unwitnessed falls in common area
Injuries: Small skin tear to right elbow, bruising to left shoulder
Post fall assessment was completed prior to transfer to an outside facility emergency department for further evaluation.

Date/Time: 12/15/2024 at 3:48 AM
Incident Type: Unwitnessed fall in common area
Injuries: Laceration to right side of scalp and hematoma noted as well as hematoma and bruising noted to right shoulder
No post fall assessment was completed prior to transfer to an outside facility emergency department for further evaluation.

Date/Time: 12/17/2024 at 4:28 AM
Incident Type: Unwitnessed fall from geri chair
Injuries: Laceration to left forehead
No post fall assessment was completed prior to transfer to an outside facility emergency department for further evaluation.

Review of Patient #1's Fall Risk Assessments revealed in part:
Date/Time of Assessment: 12/10/2024 at 9:18 PM
Type of Assessment: Admission Fall Assessment
Mental Status: Confusion/Disorientation
Elimination: Independent with control of bowel/bladder
Medications: Cardiac Medications
Diagnosis: Dementia/Delirium
Ambulation/Balance: Unsteady/Requires Assist and Aware of Abilities
History of Falls: No history of falls
Assessment Total Score: 98
Electronically Signed by: S7RN

Date/Time of Assessment: 12/14/2024 at 10:05 PM
Type of Assessment: Post Fall Assessment
Mental Status: Agitation/Anxiety; Confusion/Disorientation
Elimination: Elimination with Assist; Altered elimination (incontinence, nocturia, frequency)
Medications: Cardiac Medications; Psychotropic Medications (including benzodiazepines and antidepressants)
Diagnosis: Dementia/Delirium
Ambulation/Balance: Unsteady but Forgets Limitations
History of Falls: History of falls in the last 3 months
Assessment Total Score: 145
Electronically Signed by: S8RN

Date/Time of Assessment: 12/17/2024 at 5:23 PM
Type of Assessment: Post Fall Assessment
Mental Status: Confusion/Disorientation
Elimination: Altered elimination (incontinence, nocturia, frequency)
Medications: Cardiac Medications; Psychotropic Medications (including benzodiazepines and antidepressants)
Diagnosis: Dementia/Delirium
Ambulation/Balance: Unsteady/Requires Assist and Aware of Abilities; Unsteady but Forgets Limitations
History of Falls: History of falls in the last 3 months
Assessment Total Score: 127
Electronically Signed by: S8RN

On 03/06/2025 at 12:28 PM, an interview was conducted with S1QD. She confirmed post fall reassessments were not completed for Patient #1 after her fall on 12/15/2024 and 12/17/2024 and should have been.

Patient #2
Review of Patient #2's medical record revealed she was admitted to the hospital on 01/14/2025 at 8:30 PM for Psychosis Aggression with secondary diagnoses of Mild Mental Retardation with an I.Q. of 50-70; Bipolar Type 1 Disorder; Dementia with Mood Disturbances; and Oppositional Defiant Disorder.

Review of Patient #2's Incident Reports revealed in part:
Date/Time: 01/15/2025 at 1:25 AM
Incident Type: Fall
Injuries: Patient #2 denies hitting her head and had no obvious injuries noted
Post fall assessment was not completed.

Date/Time: 01/15/2025 at 3:50 PM
Incident Type: Fall
Injuries: Small hematoma to posterior, left side
Post fall assessment was not completed prior to transfer to outside facility emergency department for further evaluation.

Date/Time: 01/16/2025 at 2:55 AM
Incident Type: Fall
Injuries: None
Post fall assessment was not completed.

Review of Patient #2's Fall Risk Assessments revealed in part:
Date/Time of Assessment: 01/15/2025 at 11:32 AM
Type of Assessment: Admission Fall Assessment
Mental Status: Agitation/Anxiety; Confusion/Disorientation
Elimination: Elimination with Assist
Medications: Psychotropic Medications (Including Benzodiazepines and antidepressants)
Diagnosis: Major Depressive disorder
Ambulation/Balance: Proper use of Assistive Devises (cane, walker, w/c)
History of Falls: History of falls in the last 3 months
Assessment Total Score: 94
Electronically Signed by: S10RN

On 03/06/2025 at 12:30 PM an interview was conducted with S1QD. She confirmed post fall reassessments were not completed for Patient #2 after either fall on 01/15/2025 or the fall on 01/16/2025 and should have been.

Patient #3
Review of Patient #3's medical record revealed she was admitted to the hospital on 02/26/2025 at 12:00 AM from an outside referring emergency department for Major Depressive Disorder.

Review of Patient #3's Incident Reports revealed in part:
Date/Time: 02/26/2025 at 4:00 PM
Incident Type: Fall
Injuries: None visible and/or reported
Post fall assessment was not completed.

Review of Patient #3's Fall Risk Assessments revealed in part:
Date/Time of Assessment: 02/26/2025 at 4:15 AM
Type of Assessment: Admission Fall Assessment
Mental Status: Agitation/Anxiety; Intermittently Confused
Elimination: Altered elimination (incontinence, nocturia, frequency)
Medications: Psychotropic Medications (Including benzodiazepines and antidepressants)
Diagnosis: Major Depressive disorder
Ambulation/Balance: Proper use of Assistive Devices (cane, walker, w/c)
History of Falls: History of falls in the last 3 months
Assessment Total Score: 111
Electronically Signed by: S11RN

On 03/06/2025 at 12:22 PM an interview was conducted with S1QD. She confirmed a post fall reassessment was not completed for Patient #3 after a fall on 02/26/2025 and should have been.

Patient #4
Review of Patient #4's medical record revealed he was admitted to the hospital on 02/13/2025 at 8:15 PM from an outside referring facility emergency department for Suicidal Ideations and Dementia.

Review of Patient #4's Incident Reports revealed in part:
Date/Time: 02/14/2025 at 5:50 AM
Incident Type: Fall
Injuries: 4cm Laceration to middle of forehead
Post fall assessment was not completed prior to transfer outside facility emergency department for further evaluation.

Review of Patient #4's Fall Risk Assessments revealed in part:
Date/Time of Assessment: 02/14/2025 at 1:34 AM
Type of Assessment: Admission Fall Assessment
Mental Status: Intermittently confused
Elimination: Independent with control of bowel/bladder
Medications: Cardiac Medications
Diagnosis: Dementia/Delirium
Ambulation/Balance: Proper use of Assistive Devices (cane, walker, w/c)
History of Falls: No history of falls
Assessment Total Score: 93
Electronically Signed by: S12RN

On 03/06/2025 at 12:20 PM an interview was conducted with S1QD. She confirmed a post fall reassessment was not completed for Patient #4 after his fall on 02/14/2025 and should have been.

Patient #5
Review of Patient #5's medical record revealed he was admitted to the hospital on 02/24/2025 at 6:15 PM from his nursing home for Schizoaffective Disorder.

Review of Patient #5's Incident Reports revealed in part:
Date/Time: 03/05/2025 at 8:40 PM
Incident Type: Unwitnessed fall
Injuries: Old skin tears to bilateral arms, elbows and top of hands opened and bleeding; no additional injuries noted
Post fall assessment was completed inaccurately.

Review of Patient #5's Fall Risk Assessments revealed in part:
Date/Time of Assessment: 02/24/2025 at 11:02 PM
Type of Assessment: Admission Fall Assessment
Mental Status: Agitation/Anxiety; Intermittently Confused
Elimination: Independent with control of bowel/bladder
Medications: Psychotropic Medications (Including benzodiazepines and antidepressants)
Diagnosis: Bipolar/Schizoaffective Disorder
Ambulation/Balance: Independent/Steady gait/Immobile
History of Falls: History of falls in the last 3 months
Assessment Total Score: 106
Electronically Signed by: S13RN

Date/Time of Assessment: 03/05/2025 at 2:07 AM
Type of Assessment: Post Fall Assessment
Mental Status: Intermittently confused
Elimination: Altered elimination (incontinence, nocturia, frequency)
Medications: No medications
Diagnosis: Dementia/Delirium
Ambulation/Balance: Unsteady/Requires Assist and Aware of Abilities
History of Falls: History of falls in the last 3 months
Assessment Total Score: 103
Electronically Signed by: S14RN

On 03/06/2025 at 12:20 PM an interview was conducted with S1QD. She confirmed a post fall reassessment was completed for Patient #5 after his fall on 03/05/2025, however it was completed inaccurately by not indicating the accurate medication types and diagnosis types for Patient #5. She confirmed by correctly indicating the proper medication types he had been receiving and his additional diagnosis of schizoaffective disorder which he was admitted with, it would have increased his total fall risk assessment score.

Patient #6
Review of Patient #6's medical record revealed she was admitted to the hospital on 02/24/2025 at 7:15 PM from an outside referring facility's emergency department for Psychosis.

Review of Patient #6's Incident Reports revealed in part:
Date/Time: 03/03/2025 at 10:30 AM
Incident Type: Witnessed fall in day room
Injuries: None reported
Post fall assessment was completed inaccurately.

Review of Patient #6's Fall Risk Assessments revealed in part:
Date/Time of Assessment: 02/25/2025 at 4:26 AM
Type of Assessment: Admission Fall Assessment
Mental Status: Agitation/Anxiety; intermittently confused
Elimination: Altered elimination (incontinence, nocturia, frequency); Incontinent by ambulates independently
Medications: Cardiac Medications; Psychotropic Medications (Includes benzodiazepines and antidepressants)
Diagnosis: Bipolar/Schizoaffective Disorder; Substance Abuse/Alcohol Abuse
Ambulation/Balance: Independent/Steady gait/Immobile
History of Falls: History of falls in the past 3 months
Fall Risk Score: 90 or above
Assessment Total Score: 124
Electronically Signed by: S11RN

Date/Time of Assessment:
Type of Assessment: Post Fall Assessment
Mental Status: Intermittently confused
Elimination: Independent with control of bowel/bladder
Medications: Psychotropic Medications (Including benzodiazepines and antidepressants)
Diagnosis: Bipolar/Schizoaffective Disorder; Substance abuse/Alcohol abuse
Ambulation/Balance: Unsteady/Requires Assist and Aware of Abilities
History of Falls: History of falls in the past 3 months
Fall Risk Score: 89 or below
Assessment Total Score: 87
Electronically Signed by: S15RN

On 03/06/2025 at 12:20 PM, an interview was conducted with S1QD. She confirmed a post fall reassessment was completed for Patient #6 after her fall on 03/05/2025, however it was completed inaccurately by not indicating the accurate medication types and including the addition of PRN psychotropic medications received within the last 24 hours for Patient #6. She confirmed by correctly indicating the proper medication types she had been receiving and including the addition of the PRN psychotropic medications she had received within the prior 24 hours, it would have increased her total fall risk assessment score.

2) Failure to re-educate staff on implementation of preventive measures and documentation of the use of those measures for each patient on fall precautions.

Review of the incident log revealed on 02/14/2025 Patient #4 slipped while leaving the restroom. Patient #4 was taken to an acute care hospital and diagnosed with cervical spine fracture.

Review of the medical record for Patient #4 revealed admission on 02/14/2025. Review of the admission orders revealed Patient #4 was placed on fall precautions. Further review of the medical record revealed the patient did receive the required yellow band, but there was no documentation of initiation of any of the other preventive measures.

On 03/05/2025 at 3:50 PM, an interview was conducted with S5QA who confirmed there was no documentation by the nurse that the patient was told to put the non-skid socks on his feet. S5QA confirmed the non-skid socks are routinely placed in the bucket that was given to patients at the time of admission.

On interview at 03/06/2025 at 2:10 PM, S1QD confirmed she had watched the video of the incident and Patient #4 was not wearing his non-skid socks at the time of the fall. S1QD confirmed the facility was in the process of educating the nursing staff about the fall precautions, but the education did not focus on the documentation of implementation of the measures.

Based on record review and interviews, the hospital failed to ensure neuro checks were completed as ordered by the physician on 1 (#1) of 2 (#1 - #2) patients reviewed for a fall with head injury.
Findings:

Review of the hospital's policy number NSG-02 titled, "Documentation" last revised on 01/01/2023, revealed in part:
"Purpose: To maintain a comprehensive and chronologically continuous account of treatment delivered to a patient by nursing staff. To provide specific information regarding medications, treatments, and observations which reflects the care and progress of the patient. To increase communication among the various disciplines providing care to the patient. To provide concise and comprehensive information as a part of a legal document.
Policy: Inpatient nursing personnel document patient's progress every 12-hour shift, incorporating the elements of the nursing process and patient's treatment goals and progress within the patient's medical record. Nursing documents as a member of the multidisciplinary treatment team.
Procedure: Inpatient - Routine 3. Documents the implementation and execution of physician and NPP orders."

Review of Patient #1's medical record revealed she was admitted to the hospital on 12/10/2024 at 7:45 PM from an outside referring facility's emergency room for dementia with behavioral disturbances.

Review of Patient #1's Physician's Orders revealed in part:
Neuro Checks Every Hour For 1 Day Start 12/17/2024 at 2:15 PM End 12/18/2024 at 1:15 PM
Neuro Checks Every 2 Hours For 3 Days Start 12/19/2024 at 1:00 PM End 12/22/2024 at 11:00 AM

Review of Patient #1's Neurological Flow Sheets for 12/17/2024 to 12/22/2024 revealed in part:
No neuro check documentation every hour from 12/17/2024 at 7:15 PM to 12/18/2024 at 1:15 PM.
No neuro check documentation every two hours from 12/19/2024 at 1:00 PM to 12/20/2024 at 7:00 AM; from 12/20/2024 at 7:00 PM to 12/21/2024 at 7:00 AM; and from 12/21/2024 at 5:00 PM to 12/22/2024 at 11:00 AM.

On 03/05/2025 at 11:50 AM, an interview was conducted with S5QA during patient record review. She confirmed Patient #1 had neuro checks ordered and were not completed during the above mentioned time frames and should have been.

Based on record review and interviews, the hospital failed to ensure the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needed. This deficient practice was evidenced by the failure to update the care plan of 1 (#2) of 6 (#1 - #6) patients reviewed for completed and updated care plans.
Findings:

Review of the hospital policy CS-02 titled, "Treatment Planning, Integrated/Multidisciplinary," last revised on 07/01/2024 revealed in part:
"Procedure: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided.
Policy: The treatment plan includes defined problems and needs, measurable goals and objectives based on assessed needs and identified by the patient, strengths and limits, frequency of care, treatment and services, facilitating factors and barriers, and transition criteria to lower levels of care.
Procedure:
2. The admitting nurse is responsible for the following:
-Formulating the initial treatment plan based on physician's orders/initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment, related measurement-based tools and family/significant other information within 24 of admit or sooner if patient's needs warrants immediate action.
-Implementing immediate treatment interventions for safety and stabilization of the patient.
-Specifying and including at least one long or short-term individualized goal statement that identifies a specific and qualifying measurement-based tool that contributes directly to the patient's plan of care and is directly related to the patient's primary diagnosis.
-Ensure that this preliminary plan of care addresses presenting needs.
-Initiating individualizing treatment problem/nursing diagnosis list as identified in the assessment.
-Revising and developing nursing and medical components of the treatment plan based on additional findings from patient assessments, problems, needs, strengths and limitations, and physician's orders.
-Revising the plan based on changes in condition and physician's orders. All physician's orders will be incorporated into the Treatment Plan."

Review of Patient #2's medical record revealed she was admitted to the hospital on 01/14/2025 at 8:30 PM from an outside referring facility's emergency room with a primary diagnosis of psychosis aggression and secondary diagnoses of mild mental retardation (I.Q. 50-70); Bipolar Type 1; Dementia with Mood Disturbance and Oppositional Defiant Disorder.

Review of Patient #2's Physician's Orders revealed the following medications in part:
Depakote DR 500mg PO BID for Bipolar
Lamictal 100mg PO BID for Bipolar
Prozac 20mg PO Daily for anxiety
Risperdal 3mg PO BID for Bipolar
Seroquel 200mg PO BID for Bipolar
Vistaril 50mg PO Q8H PRN for anxiety

Review of Patient #2's Medication Administration Record revealed Vistaril 50mg PO Q8H PRN for anxiety was administer on the following date and times:
01/16/2025 8:18 PM given; effectiveness documented at 01/16/2025 11:17 PM
01/17/2025 8:53 AM given; effectiveness documented at 01/17/2025 9:53 AM
01/17/2025 8:19 PM given; effectiveness documented at 01/17/2025 10:04 PM
01/18/2025 8:45 AM given; effectiveness documented at 01/18/2025 9:45 AM
01/18/2025 8:10 PM given; effectiveness documented at 01/18/2025 10:52 PM
01/19/2025 9:25 AM given; effectiveness documented at 01/19/2025 10:25 AM

Review of Patient #2's Complete Plan of Care revealed no documented care plan problems related to bipolar mood, anxiety or the number of psychotropic medications she was prescribed.

On 03/05/2025 at 2:10 PM, an interview was conducted with S5QA during patient record review. She confirmed there were no care plan problems in Patient #2's Complete Plan of Care related to her secondary diagnosis of Bipolar Type 1 or for her PRN anxiety or the number of other psychotropic medication she was prescribed and receiving while as patient in the hospital and there should have been.

Based on record review and interviews, the hospital failed to ensure all patient treatments were within compliance of particular aspects of the patients' individual treatment program as evidenced by failure to have a signed master treatment plan by the nurse and social worker/therapist for 1 (#2) of 6 (#1 - #6) patients' treatment plans reviewed for the sample.
Findings:

Review of the hospital's policy number CS-02 titled, "Treatment Planning; Integrated/Multidisciplinary" last revised on 07/01/2024, revealed in part:
"Purpose: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided.
Policy: The multi-disciplinary treatment team, under the direction and supervision of the attending physician, shall develop an integrated written, comprehensive Treatment Plan with specific goals and objectives necessary to address deficits and cultivate strengths identified in the assessments process with continual development and formulation by the attending physician and multi-disciplinary treatment team, with the patient's involvement, throughout the course of treatment.
Procedure:
4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or unwilling to sign the treatment plan, the reason or circumstances of such inability or unwillingness shall be documented in the patient's medical record."

Review of Patient #2's medical record revealed she was admitted to the hospital on 01/14/2025 at 8:30 PM from an outside referring facility emergency room for psychosis aggression.

Review of Patient #2's Interdisciplinary Treatment Plan Master Sheet dated 01/15/2025 at 10:10 AM revealed the patient signature line was signed by S6SW, but no additional documentation stating Patient #2 was unable and/or unwilling to sign was provided. Further review revealed no staff signatures from the nurse, therapist or MD.

On 03/05/2025 at 1:45 PM, an interview was conducted with S5QA during patient record review. While reviewing Patient #2's Master Treatment Plan, she confirmed S6SW signed on the patient signature line, but did not provide any documentation as to why Patient #2 was unable and/or unwilling to sign. S6QA also confirmed
There was no signature for the nurse and the therapist on the Master Treatment Plan and there should have been. She also confirmed there was no signature for the MD, but further stated there was ongoing open education related that from a prior survey citation.