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Based on review of patient medical records, staff interviews, and records review the facility failed to have an organized nursing service as evidenced by the nursing staff failing to develop and maintain a nursing care plan that reflected the patient's needs; the nursing staff failed to maintain fall interventions to ensure the patient's safety. A root cause analysis was performed by the facility after patient #1's fall on 5/28/21, with a fall action plan completed on 8/31/21. Review of facility's fall log revealed 21 falls for September and 26 falls for October 2021, demonstrating an increase in frequency of falls. The cumulative effect of this system failure resulted in patient # 1 falling and sustaining a significant and critical head injury (Refer to 0396).

Based on a review of patient medical records, hospital policies and procedures, staff interviews, and record reviews, the facility failed to ensure that the nursing staff developed and maintained a current plan of care containing interventions that reflect patient #1's goals and needs.

Findings include:

~Patient #1 fell getting out of bed and suffered a head injury on 5/28/21 at 0750 am. Patient #1 received a post-fall computed tomography (CT) scan of his brain on 5/28/21 at 0800 am, showing a "Large extracranial scalp hematoma" and "No acute traumatic intracranial abnormalities."

~On 5/28/21 at 1700 patient #1 was found unresponsive by transport medics. Staff # 11 documented, "Ambulance arrived to pick pt [patient] up for discharge. I gave report and took outpatient IV [intravenous catheter] . . . Pt looked like he was asleep. . . EMS [emergency medical service] and I tried to wake pt to transfer to EMS bed. Pt would not wake up."


~Patient #1 had a repeat brain CT scan on 5/28/21 at 1735 pm that showed a "Massive acute right-sided subdural hematoma with subfalcine and uncal herniation." Patient #1 died on 5/29/21 with a time of death of 1032 am.

~ During an interview on 11/10/21 at 1137 am, staff #2 stated, the facility he came from "provided the sitter for him."

~A review of patient #1's medical record revealed nursing staff documented "sitter at the bedside," referring to the patient advocate accompanying patient #1 from his residential facility multiple times during patient #1's hospitalization.

~During an interview on 11/10/21 at 1150 am, staff # 6 stated, "The post-fall huddle was performed. The sitter was watching the patient during the night and thought he was asleep. She went to the restroom inside the room. When the sitter came out of the bathroom, the patient was standing up and starting to fall. . . The nurse turned the bed exit alarm off because there was a sitter with the patient ."

~A review of the facility's Sitter Utilization policy failed to reveal the facility's definition of a sitter, the training requirements, and validation methods. A review of the facility's fall log revealed increasing fall rates totaling 21 falls in September and 26 falls in October, despite implementing patient #1's incident corrective action plan.

During an interview on 11/15/21 at 1030 am with the residential facility's director of operations, staff #12 stated, "The patient advocate is sent to the facility to provide the same level of observation the patient would receive at this facility. They are not trained to provide inpatient hospital level of monitoring. . . He [patient #1] was ordered 1 to 1 monitoring while awake and every thirty minute checks while asleep."

On 11/10/21 at 1345, staff #8 stated, "We have not added any other fall interventions because we have the action plan in place."

On 11/10/21 at 1400, staff #6 validated that the bed alarm should not have been turned off. Staff #6 stated, "I understand that there needs to be more clarification on who is considered a sitter and a patient advocate. There needs to be better clarity on what patient advocates do."