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Based on observation and interview the facility failed to ensure the privacy of patients when erase boards revealed the first three initials of the patient's last name which was visible to the public; and when staff did not draw curtains or close the patient's door for privacy when examining two (Patient #3 and Patient #27) of 27 patients. The facility census was 66.

Findings included:

1. Observation on 10/12/10 at 1:40 p.m. on 3 North, 3 Center and 3 South units showed a white erase board approximately 2 x 4 feet located at the nursing station that was viewable to the public and included the first three initials of the patient's last name.

2. Observation on 10/12/10 at 2:00 p.m. showed Physician E entered the room of Patient #3 and uncovered and examined the patient's lower legs. Physician E did not draw the curtain or close the door to prevent exposing the patient to anyone who walked by the room.

3. Observation on 10/12/10 at 2:15 p.m. showed Physician E entered the room of Patient #27 and uncovered and examined the feet and left leg of the patient. Physician E did not draw the curtain or close the door to prevent exposing the patient to anyone who walked by the room.

4. During an interview on 10/13/10 at 2:30 p.m. the Director of Respiratory and Laboratory, Staff B confirmed privacy was not provided to Patient #3 and Patient #27.

Based on interview and record review the facility failed to thoroughly investigate the reasons for falls, failed to document interventions to prevent falls and injury for three patients, and failed to implement and/or document interventions per facility policy for three (Patient #19, #24 and #25) of three patient medical records reviewed for fall precautions. The facility census was 66.

Findings Included:

1. Review of Patient #19's History and Physical dated 08/08/10 revealed the patient was admitted on 08/07/10 with diagnoses of respiratory failure and a cerebellar infarct (stroke).

Review of the patient's fall risk assessment dated 08/07/10 revealed the patient was considered a high fall risk (any score above ten) with a score of "11."

Review of the patient's care plan (on 10/13/10) for Potential for injury related to impaired sensory-perception, impaired thought process, unfamiliar surroundings, medication with fall risk potential, dated 08/08/10, revealed a goal the patient will not experience injury as measured by no falls. Interventions included to assist with cares, provide adequate light, obtain a restraint order if necessary, and maintain side rails in the upright position, half, continuously.

Review of a facility policy entitled, "Fall Prevention," revised 05/2009, revealed staff were to identify the main components of an effective multiple intervention program through the following:

a) Appropriate individualized interventions
b) Thorough documentation
c) Assessment and regular evaluation and re-evaluation.
d) Those patients identified as high fall risk will have interventions added to their care plan such as, use of bed alarms, needs in staffing, falling risk stars signs, etc.
e) Nursing leadership analyzes the results of a fall investigation and forwards the analysis to the Director of Quality Management.

Review of an After Fall Assessment Worksheet, dated 09/08/10, revealed the following:

a) Patient #19 had been found on the floor at 1:00 a.m.
b) Patient #19 had been confused, and was bedbound prior to being found.
c) There had been no falling star sign (indicating fall risk) on the door of the patient's room.
d) There were no alarms in use.
e) Staff completing the Worksheet failed to document how/where exactly the patient was found. The COMMENTS and ACTIONS TAKEN sections of the Worksheet were blank.

Review of nursing assessments and notes from 09/08-17/10 (after the fall) revealed the patient had various stages of a scratch, scrape, swelling, abrasions, and bruising to the face.

During an interview on 10/14/10 at 8:40 a.m., Physician W said the patient was confused, and frequently agitated. Physician W said the patient suffered extensive bruising and swelling to the face as a result of the fall. Registered Nurse Staff Member X also said alarms had not been utilized in this facility lately, and that they only owned two.

Review of CT reports dated 09/09/10 revealed the patient suffered a fracture of the medial right lamina papyracea (nasal/orbital bone), there is prominent swelling over the right facial region wrapping around the frontal lobe, there is collection suggesting hematoma below the right eye.

Even though requested, staff could not provide documented evidence (with the exception of one instance when a floor mat was used) whereby consistent, individualized interventions were instituted to prevent this, and further falls.


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2. Record review of the facility's Event Report (list of incidents and accidents) dated 04/01/10 through 09/30/10 revealed the following:
-Approximately twenty seven patients sustained falls.
-Eighteen patients sustained at least one fall.
-Five patients sustained at least two falls.
-Three patients sustained at least three falls.
-One patient sustained four falls during admission.
-Approximately twenty six of the total number of falls were unwitnessed.

3. Record review of closed Patient #24's admission history and physical revealed the physician admitted the patient on 07/29/10 with diagnoses including respiratory failure with tracheostomy {a surgically created hole at the front of the neck into the windpipe or trachea} and lower respiratory infection with MRSA {methicillin-resistant staphylococcus aureus, a bacteria resistant to many antibiotics} and pseudomonas {bacteria found in wounds, burns and urinary tract infections}. Further review of the patient's admission history and physical revealed the physician assessed the patient was on a mechanical ventilator, had a urinary catheter and a feeding tube, spoke a foreign language and had problems communicating with staff, assessed the patient was appropriate, awake and alert and communicated by writing.

Record review of the patient's nurse admission assessment dated 07/29/10 at 09:40 p.m. revealed the following:
-Staff assessed vital signs.
-Assessed the patient was at risk for falls due to confusion/disorientation/sedation.
-Assessed the patient was at risk for falls due to administration of high risk medications within the last seventy two hours including haloperidol (an anti-psychotic medication) and lorazepam (anti anxiety medication).

Record review of the patients nurses notes revealed the following:
-Dated 07/30/10 at 07:26 p.m. staff assessed the patient spoke a foreign language but could understand and communicate in English.
-Dated 07/31/10 at 08:15 a.m. staff assessed the patient was restless and climbing out of bed.
-Dated 08/01/10 at 01:52 a.m. staff reinserted a urinary catheter because the patient had pulled out the original one.
-Dated 08/01/10 at 06:00 a.m. staff assessed the patient was very anxious throughout the night, had episodes of vomiting.
-Dated 08/02/10 at 12:14 a.m. staff assessed the patient had episodes of anxiety on and off and was medicated plus the patient had complaints of back pain and was administered morphine.
-Dated 08/02/10 at 06:25 a.m. staff assessed the patient had episodes of high anxiety and back pain, successfully treated with medication for a few hours then, the patient reawakens with problems and complaints.

Record review of the patient's Incidents and Accidents report forms revealed an unwitnessed fall from bed in the Intensive Care Unit (ICU) dated 08/11/10 at 05:45 p.m.

Further record review of the patient's After Fall Assessment Worksheet dated 08/04/10 revealed staff described the fall as follows:
-Occurred on 08/04/10 at 04:30 p.m. (incongruent with the time on the incident and accident report).
-Staff described the patient as alert and agitated.
-Recorded no bed or chair alarms were used.
-Recorded two of four side rails were used.
-Recorded the patient was found on the floor at the bedside leaning against the bed.
-Recorded the patient was re-oriented to use the call light instead of attempting to get out of bed alone. Needs understanding. Continue to monitor closely.

Record review of the patient's Incidents and Accidents report forms revealed a second fall from bed in the ICU dated 08/16/10 at 12:30 p.m. Further record review of the patient's After Fall Assessment Worksheet dated 08/16/10 revealed staff described the second fall as follows:
-Was witnessed.
-Recorded the patient slid down to the floor onto mats.
-Was unable to communicate with staff.
-Was on a low bed.
-Did have a history of falls.
-Was restrained.
-Did not have a bed or chair alarm on.
-Four side rails were not in use.
-No description of actions taken after the fall were recorded by staff.
-Staff failed to document any actions taken to prevent future falls.

Record review of the patient's Incidents and Accidents report forms revealed a third fall from bed in the ICU dated 08/18/10 at 01:19 a.m. Further record review of the patient's After Fall Assessment Worksheet dated 08/18/10 revealed staff described the third fall as follows:
-A fall from bed in a room (incongruently) on another floor dated 08/18/10 at (incongruently) 03:30 a.m.
-Was not witnessed.
-The patient was assessed as alert and confused.
-Was unable to communicate with staff.
-Had a history of falls.
-Was restrained.
-Did not have a bed or chair alarm on.
-Four side rails were not in use.
-Recorded comments that the patient was very agitated. Wrist restraints were intact and two side rails were up. Low boy bed was used and soft pads were on the floor.
-Actions taken were "continue to monitor patient for safety".

Record review of the patient's Incidents and Accidents report forms revealed a fourth fall from bed (unwitnessed) in the ICU dated 08/19/10 at 03:45 p.m. Further review revealed staff assessed the patient was hearing and speech impaired, had periods of agitation of confusion and was sedated or lethargic. Staff also assessed the patient was on one to one observation due to multiple falls and the patient slid out of bed onto floor mats when the one to one staff stepped out of the room.

4. Record review of closed Patient #25's admission history and physical revealed staff admitted the patient on 07/06/10 with diagnoses including ventilator dependent respiratory failure, pneumonia, lung and heart problems, anemia, chronic pain syndrome, anemia and diabetes.

Record review of the patient's nurse admission assessment dated 07/07/10 at 01:58 a.m. revealed staff assessed the following:
-The patient was at risk for falls due to confusion/disorientation/sedation.
-The patient was at risk for falls due to administration of high risk medication including fentanyl (opium derived pain reliever) and haloperidol (anti-psychotic medication) within the last seventy two hours.
-Patient was unable to speak (due to tracheostomy in place).
-Had a urinary catheter in place.
-Had a feeding tube in place.

Record review of the patient's Incident and Accidents report forms revealed an unwitnessed fall from bed dated 07/12/10 at 10:00 p.m. Further review revealed staff assessed the patient was alert, in restraints, no side rails used, no bed or chair alarms were used when the patient was found on floor. Staff failed to document any actions taken to prevent falls.

5. During an interview on 10/14/10 at 08:10 a.m. the Director of Education stated the following:
-The facility did not have a formalized training session on fall prevention techniques.
-Staff were provided fall/accident prevention education via posters on the units.
-He/she provided copies of posted information provided in lieu of formalized sessions on fall prevention.

Review of copies of the fall prevention information posted on units for staff to review revealed the following:
-A poster titled Safety Measures Follow on ALL patients with bullet pointed reminders including bed in the lowest position; call light within reach; side rails (if appropriate) 2 only; personal objects within reach; environmental hazards removed; night light on. If they are a fall risk, all of the above are necessary plus, instruct to call for help; instruct them to use assistive devices; get extra help; appropriate signage and armband sticker in place.
-The posted information further directed Fall Risk Assessments are done: On admission; after a fall; change in condition and change in medication.
-The posted information further directed Medications that can increase risk of falls: hypnotics; sedatives; analgesics; psychotropics; antihypertensives; laxatives; diuretics.
-The posted information also directed Hourly Rounds, check the 4 P's 1. Position, 2. Placement, 3. Pain, 4. Personal.
-A document titled Fall Risk Assessment/Care Planning Quick Reference Guide directing staff to fall risk screenings and assessments and care planning.
-A four question test on safety measures to undertake, methods of communication risks to other care providers, education that should be provided to the patient/family and how the documentation should be done and who should complete it.

6. During an interview on 10/14/10 at 08:05 a.m. the Chief Clinical Officer (CCO), Staff Y and the Director of Quality Management (DQM), Staff X stated the following:
-On admission a falls risk assessment was completed by the registered nurse for evaluation of the patient's risk factors for falls.
-If a patient was assessed as a fall risk the staff put the patient on a low bed.
-Staff were directly to perform hourly rounding of all patients.
-If a patient sustains a fall then there was a progression of steps to use including pad on the floor and one to one observation.
-Staff should look for signs of agitation, changes in medication response or other factors.
-Use of the after fall form was an assessment of what to put in place next.
-Use of low beds was not listed on the form as an option.
-Re-education was used as an option even for confused patients because the DQM felt even a confused patient could be educated.
-The facility only had two bed alarms to use for the patients.
-The current census was 66 patients.
-The facility did use of staffing grid and patient acuity was a factor in staffing.
-Patient #24 was in the ICU during some of the falls and staff did have direct line of sight in the ICU.
-Patient #24 was moved to the ICU as a fall precaution however the patient still fell.

During an interview on 10/14/10 at 08:35 a.m. the CCO stated the following:
-The facility average daily census was in the high fifties.
-The facility had an average of three to four falls per month.

During an interview on 10/14/10 at approximately 8:50 a.m. the DQM stated the facility had two working bed alarms because the alarms tend to "leave with the patients" on discharge but felt he/she could obtain more bed alarms.


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Based on interview and record review the facility failed to modify the patient's plan of care for soft wrist restraints for two patients (Patient #6 and #19) of three current patient medical records reviewed for restraint use. The facility census was 66.

Findings Included:

1. Review of the policy titled, Use of Physical or Chemical Restraints: General Requirements, policy number H-PC 05-010, revised 11/2009 showed, in part, the following:
-Modify the care plan electronically or in writing.
-The safety issue that resulted in the need for restraints.
-Desired measurable outcome-oriented goals.
-Interventions to minimize restraint use, including attempts to use alternatives to restraints and to end use at the earliest possible time.
-Ongoing evaluation that assess the potential use of less restrictive alternatives and ends use of the restraint at the earliest possible time.
-Patient/family-education regarding."
-Assessment of the need for restraints, including the condition or symptoms that pose harm to the patient.
-Alternatives attempted.
-The type of restraint used and its purpose.
-Monitoring safe use of a restraint, including the patient's response to the restraint.

2. Review of Patient #6's Physician's Restraint Order Form, dated 10/08/10 through 10/12/10 revealed staff used soft restraints for the patient. Review of Patient #6's care plan showed no modification to the care plan to address soft restraints.

During an interview on 10/13/10 at 8:55 a.m. immediately following review of Patient #6's care plan Nurse Manager, Staff F reviewed the patient's care plan and stated staff failed to modify the care plan to address use of soft restraints.


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3. Review of Patient #19's History and Physical dated 08/08/10 revealed the patient was admitted on 08/07/10 with diagnoses of respiratory failure and a cerebellar infarct (stroke).

Review of Restraint Assessments and orders for restraint revealed the patient had been restrained with bilateral wrist restraints from 09/06-08/10, related to pulling at tubes, frequent attempts to get out of bed, and poor judgement.

Review of the patient's care plan (on 10/13/10) for Potential for injury related to impaired sensory-perception, impaired thought process, unfamiliar surroundings, medication with fall risk potential, dated 08/08/10, revealed a goal the patient will not experience injury as measured by no falls. Interventions included obtain a restraint order if necessary, patient will not remove life sustaining tubes or lines, bilateral wrist restraints to guard against pulling out lines, check circulation, and function every two hours. Staff failed to develop a specific goal regarding the use of the restraint.

Based on interview and record review facility staff failed to obtain a physician's order for soft restraints in four patients (#2, #6, #7 and #21) of four patient medical records reviewed for restraint use. The facility census was 66.

Findings Included:

Review of the policy titled, Use of Physical or Chemical Restraints: General Requirements,policy number H- PC 05-010, and revised 11/2009 in part, showed, The need for restraints must be continuously reevaluated and orders to renew the use of restraints must by entered at least once each calendar day.

1. Review of Patient #6's Physician's Restraint Order Form, dated 10/08/10 through 10/12/10 revealed staff used soft restraints for the patient and failed to obtain physician orders for those dates.

During an interview, Nurse Manager, Staff F reviewed the patient's Physician's Restraint Order Form dated 10/08/10 through 10/12/10 and stated staff failed to obtain physician orders for the soft wrist restraints.

2. Review of Patient #7's Physician's Restraint Order Form, showed the physician failed to include the time of the order for soft wrist restraints:
-09/30/10 through 10/07/10
-10/09/10 through 10/12/10

During an interview Nurse Manager, Staff F reviewed the patient's Physician's Restraint Order Forms and stated the physician failed to time the documents.


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3. Review of Patient #2's admission face sheet revealed the patient was admitted on 09/03/10. Observation on 10/13/10 at 6:46 a.m. revealed the patient had a tracheostomy (a tube inserted into the throat, connected to a ventilator so as to assist in breathing), a catheter (a tubing inserted into the bladder to remove urine), and a feeding tube.
Review of Physician Restraint order forms from 09/04-25/10 revealed the physician failed to sign orders for bilateral wrist restraints on 09/04, 09/06, 09/09, 09/19, 09/22, and 09/23/10.
During an interview on 10/12/10 at 3:10 p.m., Medical Record Director, Staff JJ stated that the physician's were expected to sign the restraint orders within 24-hours. Staff JJ said this was an ongoing issue.
During an interview on 10/14/10 at 11:33 a.m., the Director of Quality Management, Staff X stated that it was the facility's expectation the physicians sign and date the restraint orders daily.


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4. Record review of the facility Medical Staff Rules and Regulations dated 2010, paragraph V.10. Orders for Restraints directed, in part, the following:
-A written order, based on an examination of the patient by a physician, is entered in the patient's medical record within twenty-four (24) hours of the initiation of the restraint.
-Continued use of restraint beyond the first twenty-four (24) hours is authorized by an LIP {Licensed Independent Practitioner} issuing a new order if the restraint continues to be clinically justified. Such new order must be entered at least once each calendar day and is based upon a physical examination of the patient by the LIP.

5. Record review of closed Patient #21's admission history and physical revealed staff admitted the patient on 09/09/10 with diagnoses including tracheostomy for airway obstruction, cancer of the larynx, brain tumor, lung cancer, respiratory insufficiency, malnutrition, kidney disease, heart disease, diabetes, pressure ulcers, confusion and history of past strokes.

Record review of the patient's physician's orders dated 09/22/10 revealed an unauthenticated, untimed Physician Restraint Order Form without any indication of the type of restraint used.

Record review of the patient's physician's orders dated 09/23/10 revealed an unauthenticated, untimed Physician Restraint Order Form for right and left wrist restraints.

Based on interview and record review the facility staff failed to ensure patient hygiene care was provided to four (Patient #5, #7, #28 and #30) of seven patients interviewed. The facility census was 66 patients.

Findings included:

1. In an interview on 10/12/10 at 2:15 p.m. Patient #28 and the adult child of Patient #28 both stated the patient's hair has not been shampooed since admission to the facility on 09/29/10. The patient stated once a product called 1-step had been used on his/her hair but not real shampoo. The patient and adult child of the patient both stated the patient had received only two baths since admission on 09/29/10.

Review of Patient #28's nursing documentation included the following:
The Hygiene Assessment forms listed care tasks including bathing status, linen change and Foley {urinary catheter}care These forms were present on the following dates 09/30/10, 10/05/10, 10/06/10, 10/07/10, 10/09/10, and 10/10/10 but no documented notations were found that the aide provided the care tasks. Also, no documentation of bath provided (offered, provided or refused) on 09/30/10, 10/01/10, 10/02/10, 10/03/10,10/04/10, 10/05/10, 10/06/10, 10/07/10, 10/09/10, and 10/10/10.

2. In an interview on 10/12/10 at 3:00 p.m. Patient #30 stated that they had received only one bath since admission on 10/06/10 and had not received morning hygiene care and/oro mouth care since admission on 10/06/10 (six days ago).

Review of Patient #30's nursing documentation revealed the following:
The Hygiene Assessment form listed care tasks such as bathing status, linen change and Foley {urinary catheter} care. Staff failed to document care provided on 10/07/10, 10/08/10, 10/09/10 and 10/10/10.

3. In an interview on 10/14/10 approximately 11:00 a.m. Registered Nurse (RN), Staff HH revealed he/she "used trust" that the aides provided patients with baths and he/she failed to confirm with the patients that baths were being offered/provided.

4. In an interview on 10/13/10 at 6:50 a.m. Chief Operations Officer (COO), Staff Y stated the following:
-The facility has been low for aide staffing.
-Several of the aides were off duty for medical leave.
-He/she had been trying to hire staff to work on an as needed basis.
-Hiring aides on an as needed basis was difficult.
-The facility could use staffing agencies when the facility staffing was low.
-He/she was trying to avoid the use of staffing agencies.
In an interview on 10/14/10 at 8:55 a.m. COO, Staff Y, revealed the following:
-The expectation of the facility was aides will offer a bath to the patients daily.
-The aides were to document if the patient refused a bath.
-Aides were not using the correct computer screen to document offering/providing baths and because of that there was unclear documentation of provision of bath.
-Aides need training on proper use of the necessary computer screens for documentation of baths.
-He/she was unsure if the facility had a policy regarding the expectations of the aides to offer every patient a bath every day and document the refusal of the bath when the patient refused.

In an interview on 10/14/10 at 11:00 a.m. COO, Staff Y stated that the facility failed to establish a written procedure directing aides of the expectation to offer each patient a bath daily and record the patient's refusal of baths.

5. The form titled "Hygiene Assessment, "for Patient # 5 included care tasks, including bathing status, linen changes, and Foley (catheter care), but no documented notations the aide provided care tasks on 08/25/10, 08/26/10, 08/27/10, 08/29/10, 09/04/10, 09/06/10, 09/07/10, 09/08/10, 09/09/10, 09/10/10, 09/12/10, 09/13/10, 09/14/10, 09/17/10, 09/19/10, 09/20/10, 09/23/10, 09/24/10, 09/26/10, 09/30/10, 10/02/10, 10/03/10, 10/09/10, 10/10/10, and 10/11/10.

6. The form titled "Hygiene Assessment, "for Patient # 7 included care tasks, including bathing status, linen changes, and Foley (catheter care), but no documented notations the aide provided care tasks on 08/18/10, 08/19/10, 08/21/10, 08/22/10, 08/23/10, 08/25/10, 08/27/10, 08/28/10, 09/01/10, 09/04/10, 09/05/10, 09/07/10, 09/10/10, 09/11/10, 09/21/10, 09/24/10, 09/25/10, 10/03/10, 10/05/10, 10/06/10, and 10/08/10

7. During an interview on 10/13/10 at 12:00 p.m. Staff F, Nurse Manager stated that in each patients set of "Hygiene Assessments" the days that were missing were days staff failed to document care tasks.

Based on observation, interview and record review the facility failed to ensure the staff follow the facilities hand hygiene policy when staff did not cleanse their hands before and after entering a patient's room; and failed to ensure the staff follow the facility policy when staff left the rooms of patients with personal protection equipment (PPE, disposable gowns) on. The facility census was 66.

Findings Included:

Record review of the facility policy titled Hand Hygiene revised 01/2007 in part revealed the following information:
POLICY (in part):
Hand disinfection is achieved through the use of antimicrobial hand sanitizer and handwashing is achieved through use of antimicrobial soap and water.
HAND HYGIENE WILL BE PERFORMED AS FOLLOWS:
D. Before and after patient contact
F. After situation during which microbial contamination of the hands is likely to occur (i.e. contact with potentially contaminated environmental surfaces)
I. After removal of gloves.

Record review of the facility policy titled Standard Precaution revised 08/2007 in part stated the following:
PROCEDURE (in part):
PPE or personal protective equipment will be used for patient care as noted.
Gowns (a clean non-sterile gown is adequate) are worn to protect skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions. Remove soiled gown as promptly as possible, always before leaving the room . . .

1. Observation on 10/12/10 at 1:40 p.m. showed Registered Nurse (RN), Staff C entered the room of Patient #4, gloved and removed the IV tubing from the port; connected new tubing to the port (without using alcohol to clean the port) then entered information in the electronic record without removing gloves or cleansing his/her hands.

2. Observation on 10/12/10 at 2:00 p.m. showd Physician E entered Patient #3's room who was diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA) [a bacterial infection that is highly resistant to some antibiotics] without cleansing his hands. Physician E donned gloves and a gown which he/she did not tie and examined the patient's legs. Physician E left the room and removed the gown and gloves while walking down the hall. He/she disposed of the gloves and gown in the waste basket behind the nursing station. No hand cleansing was observed when Physician E left the room.

3. Observation on 10/12/10 at 3:00 p.m. showed Certified Nursing Assistant (CNA), Staff D left Patient #26's room with gown and gloves on and carrying a food tray. Note: the patient's diagnosis included positive for MRSA. CNA D walked down the hall without removing the gown and gloves, and placed the tray in a food cart.



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4. Observation on 10/13/10 at 6:15 a.m. showed Licensed Practical Nurse, (LPN), Staff N in Patient # 14's room with a blue isolation gown on over his/her neck. The gown was not over the arms or tied around the waist.

During an interview on 10/13/10 at 6:15 a.m. LPN, Staff N said it was standard practice for the gown to be worn around the neck only. The gowns usually tear if worn with arms in the sleeves and tied around the waist because the gown is too tight. The facility had no other bigger isolation gowns.