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Based on interview documentation review and observations it was determined the Hospital failed to ensure patients received care in a safe setting because the staffing levels, as defined by the Hospital, were not met on one occasion, on another occasion staff was not provided when needed to provide 1:1 observation of one of one applicable patient record reviewed and fall prevention interventions were not implemented, per hospital policy in 5 of 7 patients identified at high risk for falls.

Findings included:

I. The Hospital's staffing plan was reviewed. The plan stated for a unit patient census of 37, on the day shift, the staff level was 8 registered nurses and 5 nursing technicians.

Review of the nursing unit staffing schedule on 4/3/10 indicated the patient census during the day shift was 37. There were 7 registered nurses and 4.5 nursing technicians on duty during the day shift.

The Nurse Manager said there had been sick calls that morning and if the calls had come in prior to the day shift starting since here was no nursing supervisor who worked nights, calls to find a replacement would wait until the day nursing supervisor arrived. The Nurse Manger said the Hospital does utilize agency staff if they cannot find a staff member who is available to fill in however this was a Holiday weekend so there was probably a problem with finding replacements

II. Documentation indicated Patient #1 was admitted to the Hospital on 3/19/10 and had had 5 falls by 3/31/10 the 4th of which, on 3/29/10, had resulted in a head laceration requiring sutures.

Review of Patient #1's nursing care plan indicated since admission the Hospital falls prevention protocol and falls risk assessments performed every shift had been identified as nursing interventions. In addition safety checks were added on 3/24/10 and on 3/31/10 the utilization of an easy release belt was identified as a nursing interventions.

Patient #1's Family contacted the Patient Advocate on 4/1/10 and had requested a 1:1 sitter to keep the Patient safe. The Patient Advocate discussed the Patient Family's request with the Vice President of Clinical Services and the Director of Quality, who suggested Patient #1's risk of falls be addressed with the utilization of a Posey vest, safety checks and involving Patient #1 in rehabilitation sessions in the late afternoon as a distraction. It was recommended the Nurse Manager contact Patient #1's Family and detail what was being done for falls prevention. The Nurse Manger spoke with Patient #1's Family who decided against the utilization of a Posey vest because they felt Patient #1 could cause self harm if an attempt was made to get out of the vest. The Nurse Manager spoke with the Attending Physician regarding Patient #1's fall and elopement risk and the Attending Physician agreed to initiate a 1:1.

The Nurse Manager said she had discussed Patient # 1's Family's request and since Patient #1 became more confused in the evening the Attending Physician agreed to order the 1:1 sitter to correspond to the time when she was most confused.

Review of Patient #1's medical record indicated an order was written on 4/1/10 at 2:45 PM for a 1:1 sitter from 7:00 PM to 7:00 AM. At 2:55 PM the order was changed for the 1:1 sitter from 4:00 PM to midnight. The utilization of a 1:1 sitter was entered into Patient #1's nursing care plan.

Continued documentation review indicated while attempting to find a staff member to provided the ordered 1:1 sitter duty the Vice President of Clinical Service called and directed that a Posey vest should be utilized. Patient #1's recent history of falls was discussed with the Vice President of Clinical Services. The Vice President of Clinical Services stated that a staff member for 1:1 would not be suppled. The nursing unit would have to use the staff who were already scheduled to work and leave the unit short. The Attending Physician was informed of the conversation with the Vice President of Clinical Services.

The Nurse Manager said the individual who arranges staffing had called the Hospital's main site and had inquired about sending a nursing technician to provide the ordered 1:1. The Vice President of Clinical Services had call me back and asked me why a 1:1 was ordered. The Vice President of Clinical Services stated Patient #1 did not need a 1:1 as the Vice President of Clinical Services had been on the nursing unit earlier in the week, seen Patient #1 and knew a 1:1 was not needed. The Nurse Manager said Patient #1's Family concerns, their desire for a 1:1 and Patient #1's current status was explained however the Vice President of Clinical Service stated an additional nursing technician, to provide the 1:1 would not be authorized. The nurse unit would have to utilize the staff that was originally scheduled to work that evening.

Further documentation review indicated at 3:30 PM, on 4/1/10, one of the scheduled nursing technicians called in sick. A replacement was found to work the evening shift.

The Nurse Manager said they were able to cover the sick call with a nursing technician who was available to work however they could not get an additional nursing technician to provide the ordered 1:1. The Nurse Manager said since 1;1 could not be provided the Evening Nursing Supervisor and nursing staff were told to keep a close watch on Patient #1.

III. Review of 4/2/10, nursing documentation did not indicated a 1:1 sitter was utilized as ordered or that an easy release belt was utilized, as identified as a nursing intervention on the nursing care plan.

Review of 4/3/10, 7:37 PM patient notes documentation indicated at approximately 11:00 PM the Patient was heard yelling for help and a staff member witnessed the Patient kneeling on the floor. Documentation did not indicated a 1:1 sitter was utilized or that an easy release belt was in use.

Review of 4/1/10-4/3/10 physician orders did not indicated the order for a 1:1 sitter from 4:00 PM to midnight had been discontinued or that the utilization of the sitter was intended for only one night.


IV. An unannounced tour to the nursing unit was conducted on 4/13/10 at 8:00 AM. It was observed that seven patients (Patient #1, #2, #3, #4, #5, #6 and #7) on the unit had been identified with a red dot next to their names on the census board as being at a high risk of falling.

Review of nursing care plans for Patient #1, #2, #3, #4, #5, #6 and #7 indicated the Hospital's Fall Prevention Protocol was added to each of the patients care needs.

The Hospital 's fall prevention program policy/procedure was reviewed. Included in the strategies that must be implemented for patients at high risk [for falls] was placing red slippers on patient and ensuring that they are always on .

The Nurse Manager, who was present during the 4/13/10, 8:00 AM, tour, said a red dot was placed outside all patients at high risk for falls and red slippers were place on their feet as a mean of alerting all staff of the patient ' s fall risk.

The Nurse Educator, who was present during the 4/13/10, 8:00 AM tour and the Nurse Manager said for those patients identified at high risk for falls, the red slippers are kept on at all times.

It was observed during the 4/13/10, 8:00 AM tour of the seven patients identified on the census board as being at a high risk for falls, Patient #3 had no red dot on the door; Patient # 2 was in bed and had no slippers on, and Patient # 1, #4 and #5 had blue slippers on.

Please also refer to Tag # A-0392, A-0396

Base on interview and documentation review it was determined the Hospital failed to ensure nursing care was provided to all patients as needed in one of one applicable patient medical record reviewed.

Finding included:

Review of Patient #1's nursing care plan indicated on the day of admission, 3/19/10 Patient #1 was identified as needing a fall risk assessment performed every 8 hours and the fall prevention program protocol utilized every shift.

Review of nursing documentation did not indicate fall prevention interventions were utilized on 3/25/10. In addition documentation did not indicated a fall risk assessment was performed on 3/20/10, 3/23/10, 3/25/10, 3/31/10 or 4/6/10. Documentation also indicate a fall risk assessment was performed only once in a 24 hours period on 3/26/10, 3/27/10, 3/28/10, 3/29/10, 3/30/10, 4/1/10, on 4/2/10, 4/3/10, 4/7/10, 4/8/10 and 4/9/10.

Please also refer to Tag A-0144

Based on observations and documentation review it was determined the Hospital failed to ensure the nursing care plan was consistently implemented as written in 5 out of 7 patient medical records reviewed and in one of one applicable medical record reviewed.

Findings include

Please refer to Tag # A-0144 and A- 0392

Based on interview and documentation review it was determined the Hospital failed to ensure an accurate comprehensive analysis of the falls data was performed for the whole facility.

Findings included:

The October-December 2009 falls report was revived. Documentation indicated the threshold for the number of falls was set at 5 falls or less per 1000 patient days. The information on the number of falls submitted to the committee was provided by the nursing unit at Quincy site and the nursing units at the Boston site. The rate that was generated and reviewed at the committee utilized the total number of falls, from all nursing units, to arrive at one overall rate. The combined rate of November was above the threshold set and was the highest of the three months reviewed. Documentation did not indicate a rate was calculated and analyzed for each individual site

Review of the Summary Analysis for the October-December 2009 data indicated October was identified as the month when the rate exceeded the threshold. The summary analysis did not address the higher rate in November.

Based on interview and documentation review it was determined the Hospital failed to ensure feedback related to the analysis and actions taken for falls prevention was provided throughout the Hospital.

Findings included:

Review of October-December 2009 Falls Report documentation indicated following the analysis of the submitted data an action plan was developed. The falls reduction task force discussed the following strategies to reduce injury sustained by falls: Nurse Educator will continue ongoing education/re-education as needed on interventional strategies. Nurse Manager on K2 (Boston nursing unit) is participating in Falls intervention or rounds. Nurse managers are reviewing all patients on fall precautions to insure that a plan is in place and that the plan is implemented as documented. Therapeutic recreation is now provided on K2 (Boston nursing unit) and K3 (Boston nursing unit) daily. The therapist is building a program to incorporate a variety of behavioral interventions. Physical therapy is evaluating need for special equipment along with nursing based on individual needs. Rounds include check of alarms and restraints/function and application.

The Nursing Manager and the Nurse Educator, from the Quincy site said they were not members of the committee where the quarterly falls report was reviewed and discusses. They said they send their fall numbers in to the main hospital site in Boston but never get any feed back from the committee. They said they had no idea what the committee had identified as an action plan as it was not communicated to either of them.