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Based on a record and document review, observations and staff interviews, the facility failed to:

I. Utilize all appropriate resources to protect patients from falls. This deficiency creates the potential for serious patient injury, and it resulted in actual injury (per the hospital's incident report coding system) for eight patients (F1, F2, F3, F4, F5, F6, F7 and F8) who had fallen in the facility since 1/1/11. (Refer to B125-I)

II. Document the use of seclusion for Patient T5 who was added to the sample due to her acuity and potential need for seclusion. This patient was restricted to a seclusion room without proper authorization or review by a physician. In addition, the patient's treatment plan was not revised after the seclusion event, which may have prevented further use of restrictive treatment modalities. This failed practice is a potential safety hazard for patients, and violates patients' rights to be treated in the least restrictive manner possible. (Refer to B125-II.)

Based on record review, document review, observation and interview, the hospital failed to ensure that nursing staff replenished the emergency cart after its use. In an emergency involving patient IR1, all needed equipment was not found on the emergency cart when it was brought to the patient. In another incident involving patient M1, the emergency cart was not replenished after its use. The DON also failed to implement a monitoring system for a new Emergency cart (Quick Cart) check-off system that would have ensured compliance in checking the cart. This failed practice puts patients at risk for delays in emergency procedures. (Refer to B148-I for details).

As a result of these findings, an IMMEDIATE JEOPARDY (IJ) was declared on 7/14/11 at 5:15PM and the hospital administrator was informed. The facility provided a corrective action plan on 8/17/11. The plan was reviewed and the staff interviewed.

The IMMEDIATE JEOPARDY was removed on 8/17/11 at 10:47AM as a result of an acceptable corrective action plan as follows:

The facility revised the Quick Cart (emergency cart) policy. "The revised policy states that the cart will be: 1) checked each shift by an RN (registered nurse) after each use, 2) the charge nurse is responsible for immediately re-stocking the cart, and 3) the DON will monitor compliance by reviewing the check-off log and checking the cart himself, once a week.

Six RNs and LPNs (license practical nurse) were re-trained on the new policy by 8/17/11. The plan is to have all of the other nurses (RNs and LPNs) re-trained by 8/18/11.

The DON will come to the facility to check the cart and train staff (RN, LPN) on any shift in which the staff present have not been trained. He agreed to do this until all licensed staff is trained.

A memo was circulated on 8/17/11 "expressly prohibiting staff from raiding the stock and supplies in the Quick Cart."

"The Quick Cart instruction form has been revised to include the signatures and printed names of the Charge Nurse for all shifts."

A disciplinary action was taken regarding the night inspection that failed to properly occur (failure to maintain and re-stock the Quick Cart). The LPN responsible for the inspection on 8/16/11 is scheduled to meet with Administration this Friday (8-19-11)."

Based on record review, document review, direct observations and staff interviews, the hospital failed to:

I. Utilize all appropriate resources to protect patients from falls, including training of staff in the application and evaluation of the effective use of falls prevention protocols and devices. The facility's "Falls" policy listed procedures to be used for fall prevention, but there was no specific training provided to staff on their use. The facility also did not employ or utilize any consultant (such as a Physical Therapist) that has specialized training in use of fall prevention measures. This deficiency creates the potential for serious patient injury, and it resulted in actual injury (per the hospital's incident report coding system) for 7 of 20 patients (F2, f3, F4, F5, F6, F7 and F8) who had fallen in the facility since 1/1/11.

II. Document the use of seclusion for patient T5 who was added to the sample due to her acuity and potential need for seclusion. This patient was restricted to a seclusion room without proper authorization or review by a physician. In addition, the patient's treatment plan was not revised after the seclusion event, which may have prevented further use of restrictive treatment modalities. This failed practice is a potential safety hazard for patients, and violates patients' rights to be treated in the least restrictive manner possible.

Findings include:

I. Failure to protect patients from falls

A. Record/document review

1. Patient F2 was admitted on 7/18/11 with a diagnosis of "Major depression, recurrent, severe, without psychosis," and "Alcohol dependence." Co-morbid Axis III diagnoses included "Hypertension and COPD." On 7/18/11, the patient had an "At Risk for Falls" (ARF) score of "11" (scale has potential maximum score of 24) which determined her to be at high risk for falls. On 7/19/11, an incident report at 12:30PM documented, "Patient yelling for help in her room. Upon assessment, patient on floor, cane knocked over. Patient states [sic] was going to bed, got dizzy and fell. No abrasions bruises noted. Two small lumps noted to top right posterior head and left posterior head. Neurologic check intact. Ice to bumps on head...bed alarm placed on bed." The bed alarm was only put in place after the patient had the fall, and the fall occurred while the patient was attempting to self-transfer into the bed.

2. Patient F3 was admitted on 7/7/11 with a diagnosis of "Major depression, sever, recurrent, with psychosis," and "Dementia due to Huntington's likely." Co-morbid Axis III diagnoses included "Huntington's Chorea," and "Osteoarthritis." On 7/7/11, the patient had an ARF scale score of "15" which determined him to be at high risk for falls. On 7/10/11, an incident report at 5:15PM documented, "Pt. on side of bed. States he fell trying to get out of bed. Pt. reported pain 8/10 on head and left shoulder. Redness noted to left forehead ...Pt. confused but advised to ask for assistance with transfer." Despite this patient's diagnosis of dementia, the corrective action after the fall incident only was to "remind him to ask for assistance with further transfers."

3. Patient F4 was admitted on 6/10/11 with a diagnosis of "Major depression, recurrent, severe, with psychosis" and "Anxiety disorder." Co-morbid Axis III diagnoses included "HTN" and "status-post CVA." On 6/10/11, the patient had an ARF scale score of "12" which determined him to be at high risk for falls. The patient's "Medical History and Physical Exam," completed on 6/12/11, stated that the patient had an "old CVA with hemiplegia and hemiparesis, flaccid" and specified the following: "Activity: seated only." On 6/14/11, an incident report at 7:40AM documented, "Pt fell out of his wheelchair on to his right side. Also hit his head on water fountain. He did not lock the wheelchair or ask for assistance. Small bluish bruise to right shoulder and right knee." There was no documentation of training provided to the patient regarding the need to lock his wheelchair or application of a protective device such as a chair alarm (as listed in the Falls policy provided by the facility) to prevent a subsequent fall.

4 .Patient F5 was admitted on 5/31/11 with a diagnosis of "Schizoaffective disorder, bipolar type," and "Impulse control disorder." Co-morbid Axis III diagnoses included "HTN, GERD, DJD, and CAD." On 5/31/11, the patient had an ARF scale score of "12," which determined him to be at high risk for falls. On 6/1/11, an incident report at 6:40AM documented, "The pt. was walking down the hall and fell. MHT assisted pt. to wheelchair. Pt examined by (staff name), RN. Scratch to upper lip noted." The patient's admission "Medical History and Physical Exam," completed on 6/1/11, documented that the patient was to "ambulate with assistance" and that he was to otherwise "remain in a wheelchair." No protective device such as a chair alarm (as listed in the "Falls" policy provided by the facility) was provided to Patient F5 to prevent a subsequent fall.

5. Patient F6 was admitted on 5/5/11 with a diagnosis of "Bipolar disorder, mixed." Co-morbid Axis III disorders included "Cerebral palsy, seizure disorder, HTN, GERD, hyperlipidemia, and hydrocephalus." On 5/5/11, the patient had an ARF scale score of "10" which determined her to be at high risk for falls. On 5/6/11, the History and Physical conducted by MD1 noted the need for "Falls Precautions"; however, no assistive or protective device was specifically ordered. On 5/15/11, an incident report at 12:45PM documented, "Pt. found on floor in bedroom sitting next to bed and wheelchair. Stated that she fell attempting to get into wheelchair. Pt stated her right knee hurts 9/10."

6. Patient F7 was admitted on 5/5/11 with a diagnosis of "Major depression, recurrent, severe with psychosis" and "Dementia, AD (Alzheimer's disorder) with behavioral problems." Co-morbid Axis III disorders included "HTN, Diabetes." On 5/5/11, the patient had an ARF scale score of "19" which determined him to be at high risk for falls. On 4/7/ 11, the History and Physical conducted by MD 1 (and pulled forward to this admission per hospital policy) documented "Gait instability," and recommended "Falls precautions." However, no specific assistive or protective device was recommended. On 5/12/11, an incident report at 1 AM documented, "Pt. found on floor of bedroom by (staff name) MHT. Pt. stated he was trying to get to the bathroom. Pt. fell and hit nose and arms. Fall resulted in lacerations to the nose and right arm and left arm. Patient was bandaged by (staff name) LPN and assessed by (staff name) RN. Pt. was helped back to bed. A bed alarm was placed and pt. was instructed to use call bell for further assistance." There was no documentation that the patient (diagnosed with dementia) understood the instructions given by staff.

7. Patient F8 was admitted on 3/21/2011 with a diagnosis of "Major depression, recurrent, severe, without psychosis" and "OCD." Co-morbid Axis III disorders included "Scoliosis, osteoporosis, osteoarthritis, hypercholesterolemia, T9-T10 compression fracture, COPD." On 3/21/11, the patient had an ARF scale score of "7" which determined her to be at moderate risk for falls. On 3/22/11, the History and Physical conducted by MD 2 stated "Activities: no restrictions." On 3/31/11, an incident report at 4PM documented, "Notified by (staff name) MHT that pt. fell. Pt. on floor near bed, lying on right side. Assisted pt. back to bed, assessment done. Abrasion/bruise noted to right hip, tender, small skin tear to right elbow and abrasion noted to right head."

B. Additional Review of Current Inpatient "At Risk for Falls" (ARF) scale scores:

On 8/16/11, all inpatient charts were reviewed for patients whose "At Risk for Falls" scale scores placed them at a "High Risk for Falls" (defined per the scale as a score of 10 or greater.) Of 22 patients in the milieu on this date, 10 patients were at a high risk for falls (including sample patients S1, S2, T1 and T5) according to the scale utilized by the facility. The review revealed that approximately 45% of patients hospitalized at the facility on 8/16/11 were at high risk for falls.

C. Policy Review

The hospital policy titled "Fall Prevention Program" lists alerts and devices available to staff to reduce risk of patient falls including:

"Yellow Fall Alert Labels on front and sides of chart"
"Yellow Fall Alert Labels on Q-15 minute check sheets"
"Non skid Royal Blue Safety Threaded (sic) Slipper Socks"
"Bed sensor pads and alarms"
"Wheel Chair Sensors/alarms"
"Yellow dots on bedroom doors"
"Hip protectors"

The policy listed multiple factors that may lead to an elevated risk for falling but did not provide any guidance for when a specific protective device should be utilized. The policy also did not incorporate instructions to staff for proper application, usage, and monitoring of the procedures and devices. The "At Risk for Falls" scale attached to the policy and scored on admission for all patients requires the evaluating RN to "Consult with physician regarding the need for protective safety device and PT consult" if the patient achieves a score of 10 or higher.

D. Review of Additional Document Provided by Facility

On 8/15/11, the Hospital Administrator provided a document titled "Statement of Condition Regarding Physical Therapy Services" to the surveyor. The document stated, "Optima Specialty Hospital does not have a consulting agreement for physical therapy services. As of this date, the hospital has not utilized nor compensated any organization or practitioner for physical therapy services."

E. Staff Interviews

1. In an interview on 8/16/11 at 1:10PM, RN 1 and RN 2 were asked how a specific assistive device was chosen for a patient determined to be at risk for falls. RN 1 answered, "We use our nursing judgment. We don't call the doctor for any specific order." Both RN 1 and RN 2 stated that they had not received any special training in the assessment of a patient's need for an assistive device. RN 2 noted that fall prevention orders were sometimes handled by the physician who performs the patient's physical exam, and said "but they generally just reorder what the patient came in with." RN 2 acknowledged that a patient's gait and risk for falls could change with psychotropic medicines newly initiated or changed on admission by the Attending Psychiatrist. Both RN 1 and RN 2 acknowledged that most of the patients served by the facility (due to its special focus on gero-psychiatry) were at an elevated risk for falls. When asked who reassesses the effectiveness of an assistive device once it is prescribed for a patient, RN 2 stated that this would generally wait for the aftercare provider to perform. When asked about the availability of physical therapy, RN 1 stated: "It would be nice. I come from hospitals [sic] where that is provided especially for these types of patients (referring to patients at high risk for falls)."

2. In an interview on 8/16/11 at 5:45PM, the Medical Director acknowledged that a physical therapy assessment might help to reduce the facility's rate of patient falls. The Medical Director stated "I see your concern. PT would be useful here."

II. Failure to properly use and document seclusion

A. Policy Review

A review of the Seclusion and Restraint Policy provided by the facility (Revised 12/16/09) revealed the following statement: "Seclusion is the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving."

B. Record Review

Patient T5 was admitted to the inpatient Geriatric Program on 8/11/11. Her admission diagnosis was "Schizophrenia, chronic, paranoid, with acute exacerbation." Co-morbid Axis III diagnoses included "HTN," "Diabetes Mellitus, Type 2" and "Coronary Artery Disease." The patient's treatment plan of 8/13/11 documented the need for "1:1 supervision" to manage the patient's identified problem of "Psychosis." The patient's medical record contained no specific order for seclusion or restraint as of 11 AM on 8/15/11.

C. Observation

On 8/15/11 at approximately 11AM, both surveyors, in the presence of the Director of Nursing, observed patient T5 in the room the facility utilizes for seclusion and restraint. The patient appeared to be hallucinating (singing to self and drawing on the wall with chalk). The door to this room was open. However, the exit was blocked by LPN 1 who was seated in a chair across the door threshold.

D. Staff Interviews

1. On 8/15/11 at approximately 11AM, the surveyor asked LPN 1 what she would do if patient T5 attempted to exit the seclusion room. LPN 1 replied, "I'd block her like this." LPN 1 demonstrated that she would physically prevent patient T5 from exiting the room with her outstretched arms. LPN 1 then said "and then I'd call for help." LPN 1 stated that she had successfully employed this maneuver (blocking the patient's exit from the room) earlier that morning.

2. In an interview on 8/17/11 at approximately 10AM, the DON acknowledged the unauthorized use of seclusion for Patient T5. The DON said, "I saw it myself. She (LPN 1) kept her (patient T5) in there without an order."

3. In an interview on 8/16/11 at 1:10PM, RN 1 stated that staff was having difficulty with patient T5 and said, "The doctor doesn't want her in seclusion but we can't let her out like she is. We just try to keep her in there (the seclusion room) as best as we can."

Based on record and document review, observation and staff interviews, it was determined that the Medical Director failed to:

I. Assure that emergency resuscitative equipment was maintained in proper working condition to provide timely response by staff to medical emergencies in the milieu. The nursing staff did not consistently replenish the emergency cart after its use. In an emergency involving patient IR1, all needed equipment was not found on the emergency cart when it was brought to the patient. In another incident involving patient M1, the emergency cart was not replenished after its use. An effective monitoring system for ensuring that the Emergency cart (Quick Cart) was sufficiently stocked and ready for use also was not in place. These failed practices put patients at risk for delays in emergency procedures. (Refer to B148-I for details).

II. Assure that all appropriate resources were utilized to protect patients from falls, including training of staff in the application and evaluation of the effective use of "Fall Prevention" protocols. The facility's "Falls" policy listed procedures to be used for fall prevention, but there was no specific training provided to staff on their use. The facility also did not employ or utilize any consultant (such as a Physical Therapist) that has specialized training in use of fall prevention measures. This deficiency creates the potential for serious patient injury, and it resulted in actual injury (per the hospital's incident report coding system) for 7 of 20 patients (F2, f3, F4, F5, F6, F7 and F8) who had fallen in the facility since 1/1/11. (Refer to B125-I)

III. Assure that staff followed proper procedures for the seclusion of patient T5 who was added to the sample due to her acuity and potential need for seclusion. This patient was restricted to a seclusion room without proper authorization or review by the facility. In addition, the patient's treatment plan was not revised after the seclusion, which may have prevented further use of restrictive treatment modalities. This failed practice is a potential safety hazard for patients, and violates patients' rights to be treated in the least restrictive manner possible. (Refer to B125-II)

Based on document review and interview, it was determined that the Director of Nursing (DON) failed to meet the educational and on-going training requirements necessary for his administrative position. The DON has an associate's degree in nursing and no supervision/consultation with an advanced practice RN with a master's degree in psychiatric - mental nursing. This failure potentially results in patients not receiving adequate nursing care, and may have contributed to nursing staff failures related to fall prevention measures, proper use of seclusion protocols, and maintenance of the medical emergency cart. (Refer to B148 for details).

Based on record review, document review, observations and interviews, the Director of Nursing failed to:

I. Ensure that nursing staff replenished the emergency cart after its use. In an emergency involving patient IR1, all needed equipment was not found on the emergency cart when it was brought to the patient. In another incident involving patient M1, the emergency cart was not replenished after its use. The DON also failed to implement an effective monitoring system to ensure nursing compliance in checking the emergency cart. This failed practice puts patients at risk for delays in emergency procedures.

Findings include:

A. Record/Document Review

1. Patient IR1

Patient IR1 was admitted to the facility on April 13, 2011 with a diagnosis of "Vascular dementia with depressed mood." An Incident Report dated 4/21/11 at 4:50 PM for the patient stated, "IR1 choked in [sic] food. Couldn't breath [sic]. Heimlich [emergency choaking procedure] attempted, pt let to floor, abd (abdominal) thrust performed. Suction machine brought to dining area - when uncovered there was no canister, no tubing, no yanker (Yankauer suction tip) on cart. [Patient's] O2 (oxygen) dropping. AASI (name of ambulance service) here, loaded pt on ambulance - used forceps & removed very large piece of bed [sic]-from pt's throat. O2 SAT (saturation) went up to 98%. Transferred to Regional Medical Center. Pt had pulse throughout ordeal, but no respirations for 10 minutes."

2. Patient M1

Patient M1 was admitted as a medical emergency on August 8, 2011. The psychiatric diagnoses were "Major Depression, recurrent, severe, with psychosis" and "Dementia of the Alzheimer's type with behavioral disturbance." According to an incident report (8/15/11; 8:30AM), the patient choked while eating his breakfast on August 15, 2011 at 8:20AM. The Incident Report stated that the emergency cart was used.

B. Observations and Staff Interviews

On August 15, 2011 at approximately 2:30PM, the surveyor asked the unit Charge Nurse to review the emergency cart and procedure with her. During the emergency cart review, the Charge Nurse and the surveyor discovered that the cart had not been replenished since the morning (August 15) choking incident with patient M1. The Charge Nurse said that the emergency cart is supposed to be restocked by a staff member after its use. The Charge Nurse also stated that the night nurse is supposed to check the cart nightly. However, the review of the Emergency Cart Check log revealed numerous dates when the check-offs did not occur.

The DON (Director of Nursing) came into the room when the Charge Nurse and surveyor were reviewing the emergency cart check-off log. The DON stated that there was a new Emergency cart check system. He pulled a new check off sheet (Quick Cart Instructions) from the same log book that the Charge Nurse had used in discovering the missing signatures. The new check-off sheets were under a different tab. he DON stated that he had implemented the new sheet on April 22, 2011 after IR1's choking incident. The Charge Nurse stated that she was not aware that the new sheet had replaced the original check-off log.

Review of the new Quick Cart Instruction sheets revealed 24 days when no sheets were signed, documenting that the cart had been checked. The dates of the missing documentations of emergency cart check-offs (24 dates without signatures) since May, 2011 were: May 6, 9, 10, 13, 20, 28, 29, June 3, 5, 12, 19, 24, 26, July 7, 15, 19, 21, 22, 29, and August 5, 9, 11, 13, and 14. When asked about the absence of 24 signed emergency chart check forms, the DON replied that he posted the form and told the staff to do the checks. The bottom of the cart check off form states, "Signature of person checking cart and machine: ______. Date: ____."
The night nurse for the August 16 (11-7 shift) signed one of the new forms which is supposed to verify that the cart was fully re-supplied and ready if needed. However, numerous items, including the suction canister, connection tubing for the suction canister and suction machine, O2 tubing, the French suction catheter (size 14) and normal saline were all missing from the cart when the when the day shift charge nurse and the surveyor checked the cart.

C. Policy Review

The facility had no policy or written protocol, stating who is supposed to ensure that the emergency cart is re-stocked after use.

II. Ensure that nurses used all appropriate resources to protect patients from falls, including training of staff in the application and evaluation of the effective use of "Fall Prevention" protocols and devices. The facility's "Falls" policy listed procedures to be used for fall prevention, but there was no specific training provided to nursing staff on their use. This deficiency creates the potential for serious patient injury, and it resulted in actual injury (per the hospital's incident report coding system) for 7 of 20 patients (F2, f3, F4, F5, F6, F7 and F8) who had fallen in the facility since 1/1/11.

Findings include:

A. Record/Document review

1. Patient F2 was admitted on 7/18/11 with a diagnosis of "Major depression, recurrent, severe, without psychosis," and "Alcohol dependence." Co-morbid Axis III diagnoses included "Hypertension and COPD." On 7/18/11, the patient had an "At Risk for Falls" (ARF) score of "11" (scale has potential maximum score of 24) which determined her to be at high risk for falls. On 7/19/11, an incident report at 12:30 PM documented, "Patient yelling for help in her room. Upon assessment, patient on floor, cane knocked over. Patient states [sic] was going to bed, got dizzy and fell. No abrasions bruises noted. Two small lumps noted to top right posterior head and left posterior head. Neurologic check intact. Ice to bumps on head...bed alarm placed on bed." The bed alarm was only put in place after the patient had the fall, and the fall occurred while the patient was attempting to self-transfer into the bed.

2. Patient F3 was admitted on 7/7/11 with a diagnosis of "Major depression, sever, recurrent, with psychosis," and "Dementia due to Huntington's likely." Co-morbid Axis III diagnoses included "Huntington's Chorea," and "Osteoarthritis." On 7/7/11, the patient had an ARF scale score of "15" which determined him to be at high risk for falls. On 7/10/11, an incident report at 5:15PM documented, "Pt. on side of bed. States he fell trying to get out of bed. Pt. reported pain 8/10 on head and left shoulder. Redness noted to left forehead...Pt. confused but advised to ask for assistance with transfer." Despite this patient's diagnosis of dementia, the corrective action after the fall incident only was to "remind him to ask for assistance with further transfers."

3. Patient F4 was admitted on 6/10/11 with a diagnosis of "Major depression, recurrent, severe, with psychosis" and "Anxiety disorder." Co-morbid Axis III diagnoses included "HTN" and "status-post CVA." On 6/10/11, the patient had an ARF scale score of "12" which determined him to be at high risk for falls. The patient's "Medical History and Physical Exam," completed on 6/12/11, stated that the patient had an "old CVA with hemiplegia and hemiparesis, flaccid" and specified the following: "Activity: seated only." On 6/14/11, an incident report at 7:40AM documented, "Pt fell out of his wheelchair on to his right side. Also hit his head on water fountain. He did not lock the wheelchair or ask for assistance. Small bluish bruise to right shoulder and right knee." There was no documentation of training provided to the patient regarding the need to lock his wheelchair or application of a protective device such as a chair alarm (as listed in the Falls policy provided by the facility) to prevent a subsequent fall.

4. Patient F5 was admitted on 5/31/11 with a diagnosis of "Schizoaffective disorder, bipolar type," and "Impulse control disorder." Co-morbid Axis III diagnoses included "HTN, GERD, DJD, and CAD." On 5/31/11, the patient had an ARF scale score of "12," which determined him to be at high risk for falls. On 6/1/11, an incident report at 6:40AM documented, "The pt. was walking down the hall and fell. MHT assisted pt. to wheelchair. Pt examined by (staff name), RN. Scratch to upper lip noted." The patient's admission "Medical History and Physical Exam," completed on 6/1/11, documented that the patient was to "ambulate with assistance" and that he was to otherwise "remain in a wheelchair." No protective device such as a chair alarm (as listed in the "Falls" policy provided by the facility) was provided to Patient F5 to prevent a subsequent fall.

5. Patient F6 was admitted on 5/5/11 with a diagnosis of "Bipolar disorder, mixed." Co-morbid Axis III disorders included "Cerebral palsy, seizure disorder, HTN, GERD, hyperlipidemia, and hydrocephalus." On 5/5/11, the patient had an ARF scale score of "10" which determined her to be at high risk for falls. On 5/6/11, the History and Physical conducted by MD1 noted the need for "Falls Precautions"; however, no assistive or protective device was specifically ordered. On 5/15/11, an incident report at 12:45PM documented, "Pt. found on floor in bedroom sitting next to bed and wheelchair. Stated that she fell attempting to get into wheelchair. Pt stated her right knee hurts 9/10."

6. Patient F7 was admitted on 5/5/11 with a diagnosis of "Major depression, recurrent, severe with psychosis" and "Dementia, AD (Alzheimer's disorder) with behavioral problems." Co-morbid Axis III disorders included "HTN, Diabetes." On 5/5/11, the patient had an ARF scale score of "19" which determined him to be at high risk for falls. On 4/7/11, the History and Physical conducted by MD 1 (and pulled forward to this admission per hospital policy) documented "Gait instability," and recommended "Falls precautions." However, no specific assistive or protective device was recommended. On 5/12/11, an incident report at 1AM documented, "Pt. found on floor of bedroom by (staff name) MHT. Pt. stated he was trying to get to the bathroom. Pt. fell and hit nose and arms. Fall resulted in lacerations to the nose and right arm and left arm. Patient was bandaged by (staff name) LPN and assessed by (staff name) RN. Pt. was helped back to bed. A bed alarm was placed and pt. was instructed to use call bell for further assistance." There was no documentation that the patient (diagnosed with dementia) understood the instructions given by staff.

7. Patient F8 was admitted on 3/21/2011 with a diagnosis of "Major depression, recurrent, severe, without psychosis" and "OCD." Co-morbid Axis III disorders included "Scoliosis, osteoporosis, osteoarthritis, hypercholesterolemia, T9-T10 compression fracture, COPD." On 3/21/11, the patient had an ARF scale score of "7" which determined her to be at moderate risk for falls. On 3/22/11, the History and Physical conducted by MD 2 stated "Activities: no restrictions." On 3/31/11, an incident report at 4 PM documented, "Notified by (staff name) MHT that pt. fell. Pt. on floor near bed, lying on right side. Assisted pt. back to bed, assessment done. Abrasion/bruise noted to right hip, tender, small skin tear to right elbow and abrasion noted to right head."

B. Additional Review of Current Inpatient "At Risk for Falls" (ARF) scale scores:

On 8/16/11, all inpatient charts were reviewed for patients whose "At Risk for Falls" scale scores placed them at a "High Risk for Falls" (defined per the scale as a score of 10 or greater.) Of 22 patients in the milieu on this date, 10 patients were at a high risk for falls (including sample patients S1, S2, T1 and T5) according to the scale utilized by the facility. The review revealed that approximately 45% of patients hospitalized at the facility on 8/16/11 were at high risk for falls.

C. Policy Review

The hospital policy titled "Fall Prevention Program" lists alerts and devices available to staff to reduce risk of patient falls including:

"Yellow Fall Alert Labels on front and sides of chart"
"Yellow Fall Alert Labels on Q-15 minute check sheets"
"Non skid Royal Blue Safety Threaded (sic) Slipper Socks"
"Bed sensor pads and alarms"
"Wheel Chair Sensors/alarms"
"Yellow dots on bedroom doors"
"Hip protectors"

The policy listed multiple factors that may lead to an elevated risk for falling but did not provide any guidance for when a specific protective device should be utilized. The policy also did not incorporate instructions to staff for proper application, usage, and monitoring of the procedures and devices. The "At Risk for Falls" scale attached to the policy and scored on admission for all patients requires the evaluating RN to "Consult with physician regarding the need for protective safety device and PT consult" if the patient achieves a score of 10 or higher.

D. Staff Interviews

1. In an interview on 8/16/11 at 1:10PM, RN 1 and RN 2 were asked how a specific assistive device was chosen for a patient determined to be at risk for falls. RN 1 answered, "We use our nursing judgment. We don't call the doctor for any specific order." Both RN 1 and RN 2 stated that they had not received any special training in the assessment of a patient's need for an assistive device. RN 2 noted that fall prevention orders were sometimes handled by the physician who performs the patient's physical exam, and said "but they generally just reorder what the patient came in with." RN 2 acknowledged that a patient's gait and risk for falls could change with psychotropic medicines newly initiated or changed on admission by the Attending Psychiatrist. Both RN 1 and RN 2 acknowledged that most of the patients served by the facility (due to its special focus on gero-psychiatry) were at an elevated risk for falls. When asked who reassesses the effectiveness of an assistive device once it is prescribed for a patient, RN 2 stated that this would generally wait for the aftercare provider to perform."

III. Ensure that nurses obtained physician orders and completed all needed documentations for the use of seclusion for patient T5 who was added to the sample due to her acuity and potential need for seclusion. The nursing staff restricted this patient to a seclusion room without physician orders or seclusion/restraint documentations. This failed practice is a potential safety hazard for patients, and violates patients' rights to be treated in the least restrictive manner possible.

Findings include:

A. Policy Review

A review of the Seclusion and Restraint Policy provided by the facility (Revised 12/16/09) revealed the following statement: "Seclusion is the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving."

B. Record Review

Patient T5 was admitted to the inpatient Geriatric Program on 8/11/11. Her admission diagnosis was "Schizophrenia, chronic, paranoid, with acute exacerbation." Co-morbid Axis III diagnoses included "HTN," "Diabetes Mellitus, Type 2" and "Coronary Artery Disease." The patient's treatment plan of 8/13/11 documented the need for "1:1 supervision" to manage the patient's identified problem of "Psychosis." The patient's medical record contained no specific order for seclusion or restraint as of 11 AM on 8/15/11.

C. Observation

On 8/15/11 at approximately 11AM, both surveyors, in the presence of the Director of Nursing, observed patient T5 in the room the facility utilizes for seclusion and restraint. The patient appeared to be hallucinating (singing to self and drawing on the wall with chalk). The door to this room was open. However, the exit was blocked by LPN 1 who was seated in a chair across the door threshold.

D. Staff Interview

1. On 8/15/11 at approximately 11AM, the surveyor asked LPN 1 what she would do if patient T5 attempted to exit the seclusion room. LPN 1 replied, "I'd block her like this." LPN 1 demonstrated that she would physically prevent patient T5 from exiting the room with her outstretched arms. LPN 1 then said "and then I'd call for help." LPN 1 stated that she had successfully employed this maneuver (blocking the patient's exit from the room) earlier that morning.

2. In an interview on 8/17/11 at approximately 10 AM, the DON acknowledged the unauthorized use of seclusion for Patient T5. The DON said, "I saw it myself. She (LPN 1) kept her (patient T5) in there without an order."

3. In an interview on 8/16/11 at 1:10PM, RN 1 stated that staff was having difficulty with patient T5 and said, "The doctor doesn't want her in seclusion but we can't let her out like she is. We just try to keep her in there (the seclusion room) as best as we can."