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Based on interview and record review, the facility failed to fully investigate a grievance made, in person, by a patient's family member regarding missing/lost property (Patient ID #1).

Findings included:

Telephone interview 1/2/2023 09:45 am, Pt ID #1 wife stated "I went there at least 4-5 times in person and talked to multiple people looking for my husband's clothes and they just said 'we will look for them.' " She stated she had no follow-up and was upset that no resolution had been offered as the clothes were "expensive".

Interview 1/3/2023 2:15 pm with Director of Quality, Staff ID #51, she confirmed that Patient ID #1 wife had come to the facility in the springtime and was looking for his personal clothes. She confirmed she had not registered this on the grievance log. She confirmed there had been no follow-up or grievance process instituted.

Record review of facility Policy, QM11, "Grievance Resolution Process," Originated November 11, 1999; Last revision date December 21, 2021) with Director of Quality, Staff ID #51 on 1/3/2023 at 2:15 pm. She confirmed the policy stated "5. The Director of Quality Management or designee will meet with the patient to discuss their complaint and resolve the issue if possible. If the complaint is unable to be resolved, the grievance process will be initiated. Should the grievance involve more than one specific concern, each concern will be addressed individually within the written response."

Record review of faciliy's grievance and complaint log dated 01/01/2022 through 01/01/23 failed to reveal any complaint or grievance on behalf of Patient ID #1.

Based on record review and interview, the facility failed to ensure nursing implemented fall prevention strategies and failed to carry out their fall policy for 1 patient with a fall with significant injury (Patient ID # 1).

Findings Included:

Record review of Facility "Transfer Log" dated January 1, 2022 until January 1, 2023 revealed Patient ID #1 was transferred to Memorial Hermann Northeast Hospital on 01/21/2022 via ambulance for higher level of care.

Medical record review of nursing assessment from LVN Staff ID #64 entry placed 1/19/2022 8:31 pm and 01/20/22 10:21 pm, reflected Patient ID#1 with Morse Fall Risk assessment score of 75 (> 45 equals high risk). However, "nursing interventions/safety" document "standard precautions." The fall precautions box is unchecked. "Safety measures" reflected "bed in low position, room free of clutter and trip hazards, fall bad present, non-skid footwear, fall precautions in place and side rails up x 3". The "bed alarm, chair alarm and fall mats" boxes are unchecked.
Medical record review of nursing assessment from RN Staff ID #65 on entry placed 1/20/2022 at 08:50 am, he documented Morse Fall Risks assessment score of 100. He documented that "bed alarm, chair alarm and fall mats in use".
Medical record review of nursing assessment from LVN Staff ID #57 on entry placed 01/21/2022 3:51 p.m., she documented Morse Fall Risk score 80. (High risk >45). She documented "nursing interventions/safety" as "standard precautions." The "fall precautions" box is unchecked. "Safety measures" reflect "bed in low position, room free of clutter and trip hazards, fall bad present, non-skid footwear, fall precautions in place and side rails up x 3". The "bed alarm, chair alarm and fall mats" boxes are unchecked.

Medical record review of the therapy note by PTA Staff ID #66 entered on 1/20/2022 8:29 pm for a session which occurred 1/20/2022 10:45-11:30 am stated "Subjective: patient seen supine in bed reluctantly agreeing to participate with skilled therapy stating 'I fell last night,' The nurse confirmed it. Patient reported pain very high in the left side and hip." The assessment stated "Treatment was cut short, secondary to patient becoming lethargic, in pain, and no longer engaged in skilled task. Patient made good efforts at first to participate, nurse reported, Patient said he was Okay. Nurse was informed again of patient's reported pain on the left side and hip."

Medical record review of Staff MD #67 entry 1/21/2022 12:13 & 12:14 in Patient ID#1 record -order entry for a left shoulder and hip radiograph for indication "patient reports fall yesterday with left hip pain" and "left shoulder pain after fall." Imaging report revealed radiograph exam date of 1/21/2022 at 3:18 pm and stated "fracture involving the intertrochanteric portion of the left femur."

Record review of PAM Health, Nursing Policy Nsg 22, "Fall Prevention" (Originated September 2013, Last Revision March 28, 2022) with CNO, Staff ID #52, on 1/3/2023 1:45 p.m. The policy stated "Post Fall Assessment, Initiate the Post Fall Algorithm, Complete Post fall huddle, Complete fall analysis tool and Enter the incident into the incident reporting system." She confirmed that none of the four items listed in the policy occurred after staff were made aware of his statement of a fall.

Interview 1/3/23 at 2:10pm with CNO, Staff ID #52 revealed she recalled Patient ID #1 and the fact that he was transferred to an acute facility after acquiring a fracture at the facility. She denied participating in or performing an investigation into how Patient ID #1 sustained an injury. Staff ID #52 was aware the patient stated he had fallen however there was no "post-fall huddle" performed. She confirmed there was no documentation in the medical record reflecting a known patient fall, there was no documentation by staff finding patient on the floor and assisting back to bed and she confirmed there was no provider notification of patient's statement about fall or hip pain until 1/21/22 12:14 pm when a shoulder and hip radiograph were ordered by Staff MD ID# 67 for "patient reports left shoulder and hip pain after fall." Staff ID #52 stated "the patient didn't complain of pain, did not receive pain medicine and he participated in therapy for a few days too." She confirmed the PTA Staff ID #66 Physical Therapy treatment record from 1/20/22 session timed 10:45am until 11:30 am and 1/21/22 11:45 am until 12:30 pm reflected patient had pain 9/10 in left hip for both days.

Based on interview and record review, nursing failed to ensure Registered Nurses (RN) assessed patients every twenty-four hours as per facility policy (ID# 13) and failed to implement high risk fall interventions in 3 of 3 patients (ID#s 7, 8 and 9).

Findings include:

Record of medical record for patient (ID#13) on 1/3/2023 showed that the patient's last documented assessment with RN involvement was on the day shift of 12/30/2022.

Interview with chief nursing officer (ID # 52) on 1/3/2023 at 1:15 PM stated that all patients should be assessed by an RN once every 24 hours. She went on to say that the licensed vocational nurse (LVN) can do the assessment, but the RN must co-sign.

Review of facility policy titled " Guidelines for Nursing Care," dated March 28, 2022 showed the following:

POLICY
To ensure quality patient care, certain standards of care must be upheld. the following table outlines basic nursing tasks and designates the minimum frequency...


Assessment: systemic physical assessment done and recorded- Minimum frequency: every shift and as condition changes. RN must assess once every 24 hours.




Observation on 1/3/2022 at 1045 am during facility tour with facility CNO (ID# 52) showed patient's (ID# 7, 8, and 9) with red "high risk" indication outside did not have bed alarms on.

Interview with CNO (ID#52) at the time of observation stated that patient's that are at high risk for falls should have bed alarms on as well as other prevention interventions in place.

Record review of facility policy titled "Fall Prevention," dated March 28, 2022 showed the following information:
Patients are assessed for the presence/absence of fall risk factors and given a score which identifies them as low, moderate, or high fall risk. Nurses will conduct an initial fall risk assessment. A fall assessment will then be conducted once a shift, and/or with any change in a patient's clinical status and post fall.

Risk Level MFS Action
Low <25 see Universal Fall Prevention Interventions
Moderate 25-45 see Moderate Fall Prevention Interventions
High >45 see High Risk Fall Prevention Interventions

Moderate Risk Fall Prevention Interventions
Patients who are scored "moderate risk" on the modified Morse Fall Scale ...
" Bed and/or chair alarms
High Risk Fall Prevention Interventions
These interventions are designed to be considered for patients with multiple risk factors ... They are designed to reduce severity of injuries due to falls as well as to prevent falls from reoccurring, supplementing Universal and Moderate Fall Preventions Interventions.

Based on observation, interview and record review, the facility failed ensure staff cleaned the glucometer between patient use (ID#s 9, 10 and 12).

Findings include:

Observation on 1/3/2023 at 11:10 AM showed staff (ID# 58) perform glucose testing on patient (ID#s 9, 10 and 12) without cleaning the glucometer between each use.

Interview with staff (ID #58) at the time of observation stated that the glucometer should be cleaned after each patient use but she just waits and cleans it after completing all glucose checks.

Interview with chief nursing officer (ID # 52) at the time of observation stated that the glucometer should be clean after each patient use.

Record review of facility policy titled "Blood Glucose Testing," dated March 28, 2022, showed the following:
POLICY: ...It is the responsibility of nursing administration to oversee the bedside blood glucose testing program.
Maintenance
-Cleaning exterior surface
Use only water moistened with a mild detergent or 10% bleach solution