HospitalInspections.org

Based on observation, record review, interview and policy review, the facility failed to ensure patients were supervised in the bathroom and failed to ensure fall signage was in place outside patient doors. This affected two (Patients #2 and #3) of ten patients reviewed. The census was 59.

Findings include:

1. Review of the medical record of Patient #3, who remained inpatient in the facility, revealed the patient was admitted to the facility on 01/14/23 for intense therapy post stroke. The patient's fall risk assessment on admission revealed the patient was a high fall risk. Staff used bathroom supervision, a bed and chair alarm, and a seat belt as precautionary measures to prevent the patient from falling.

A nursing note on 01/19/23 at 3:06 PM stated the nurse heard the bed alarm of the patient went off and when the nurse reached the patient's room, the patient was already on the floor on his right side. The nurse assessed the patient after the fall, all limbs normal range of motion, no complaints of pain in any part of his body. This nurse informed his attending physician, no new orders. This nurse informed his wife about the incident. Will continue to monitor.

During tour on 01/23/23 at 3:20 PM., Patient #3's room did not contain any signage indicating a fall risk.

During interview on 01/27/23 at 3:00 PM., Staff A confirmed that the facility protocol for fall prevention was not followed as Patient #3 was designated a high fall risk and the room did not contain signage of the high fall risk.

2. Review of the medical record of Patient #2 revealed the patient was transferred to the facility from an acute hospital on 12/20/22 at 11:00 AM. According to the attending physician's History and Physical, the patient had a past medical history of left lower The patient was admitted for acute inpatient rehabilitation including physical and occupational therapy due to gait and activities of daily living dysfunction.

Review of the fall risk assessment, dated 12/20/22 at 11:20 AM, documented Patient #2 was a high fall risk. Precautionary measures put in place to prevent the patient from falling included bathroom supervision requiring staying with the patient, bed and chair alarms, and a self-releasing seatbelt with an alarm. These precautionary measures remained in place throughout the patient's hospitalization.

A nursing note on 12/26/22 stated: "Patient fell coming out of the bathroom x-ray of the pelvis taken no fracture noted." An incident report was completed by a staff nurse. According to the incident report the fall occurred in the bathroom on 12/26/22 at 12:00 PM. The fall description stated that the patient was ambulating independently from the bathroom trying to go back to bed when the fall occurred. The description stated that the patient was asked if he hit his head and the patient replied that he had not and had merely hit his knee, leg, and hip. The report revealed that the physician was notified ten minutes after the incident.

During interview on 01/27/23 at 3:15 PM, Staff A stated staff members are instructed not to leave patients that are a high risk for fall alone in the bathroom. She revealed there is signage in each bathroom stating such, that is meant to be a reminder to staff. It was confirmed that the patient should not have been left alone in the bathroom.


The facility policy titled "Fall Prevention Program", effective 9/21/22, documented the fall prevention program is designed to reduce the risk of falls at the hospital with particular emphasis on patient related falls. Upon admission, plan of care for fall prevention will be initiated to include a minimum:

* Bed Alarm
* Chair Alarm
* Self Releasing Alarmed Wheelchair Belts
* Supervision in the Bathroom (stay with me)

Based on record review, interview and policy review, the facility failed to ensure a physician order was obtained for the implementation of non-violent restraints. This affected two (Patients #4 and #5) of two patients reviewed for restraints. The census was 59.

Findings include:

1. Review of the medical record of Patient #4 revealed the patient was admitted to the facility on 12/3/22 at 3:00 PM with a diagnosis of anoxic brain injury. The patient had a past medical history of syphilis, hypertension, depression, and bipolar disorder. A physician's History and Physical revealed the patient had presented to an acute hospital following head trauma and strangulation with loss of consciousness after suffering an assault. A nursing note on admission revealed the decision was made to place the patient in a enclosure bed as a restraint to prevent him from unassisted bed exit. Although the patient was placed in enclosure bed on admission, the medical record lacked documentation a physician order was obtained until 12/4/22 at 7:53 AM. Although the patient remained in the enclosure bed until discharged on 12/25/22, the medical record also lacked documentation of a physician order for use of the enclosure bed on 12/5/22, 12/6/22, 12/7/22, 12/8/22, 12/9/22, 12/14/22, 12/15/22, 12/20/22, and 12/24/22.

2. Review of the medical record of Patient #5 revealed the patient was admitted to the facility on 09/22/22 at 2:14 PM. The patient was admitted after an assault at a bar requiring a hemicraniectomy with post op requirement for wearing a helmet when out of bed. The decision was made to place the patient in an enclosure bed as a restraint after numerous attempts at getting out of bed without assistance. The patient remained in the enclosure bed from 09/22/22 through 10/18/22. The medical record lacked documentation of a physician order for restraints on 09/22/22, 10/03/22, 10/05/22, 10/06/22, 10/09/22, 10/13/22 and 10/18/22.

The facility policy titled "Use of Restraints", effective 6/24/22, documented restraints may only be initiated after careful assessment of the patient and a determination that alternatives to the use of restraint have proved to be ineffective or pose a greater safety threat than the use of restraints. Restraints require a physician order every calendar day.

Based on record review, interview and policy review, the facility failed to ensure staff notified the physician of a change of condition and failed to notify a patient's family of a fall. This affected one (Patient #2) of ten patients reviewed. The census was 59.

Findings include:

1 a. Review of the medical record of Patient #2 revealed the patient was transferred to the facility from an acute hospital on 12/20/22 at 11:00 AM. The patient was admitted for acute inpatient rehabilitation including physical and occupational therapy due to gait and activities of daily living dysfunction.

A nursing note dated 12/26/22 stated the patient fell coming out of the bathroom. An x-ray of the pelvis was taken and no fracture was noted. The incident report documented the fall occurred in the bathroom on 12/26/22 at 12:00 PM. The fall description stated that the patient was ambulating independently from the bathroom trying to go back to bed when the fall occurred. The description stated that the patient was asked if he hit his head and the patient replied that he had not and had merely hit his knee, leg, and hip. The report revealed that the physician was notified ten minutes after the incident. There was no documentation the patient's family was notified.

A post fall assessment was completed on 12/26/22 at 1:44 PM documented the patient experienced an unwitnessed fall at 12:00 PM. The patient's vital signs were taken and were within normal limits. Although the x-ray of the pelvis and hips revealed there were no fractures, the patient complained of acute onset bilateral pelvic pain. The post fall assessment documented the patient's family of the fall on 12/29/22, three days after the fall.

During interview on These facts were confirmed during interview with Staff A on 01/23/23 at 5:00 PM, Staff A verified the patient's family was not notified of the fall until 12/29/22.

The facility protocol titled "When a Patient Falls" documented at item number three, staff nurses are instructed to call the family.

b. On 12/26/22 at 9:14 PM, Patient #2's pulse was 140 beats per minute. The patient also complained of lower back pain. The patient rated the pain an 8 on a 0-10 pain scale. The medical record lacked documentation the attending physician was notified of the patient's increased pulse rate or his complaints of severe pain. According to the Medication Administration Record (MAR), the patient was medicated with 650 mg of Acetaminophen (an analgesic used to treat minor aches and pains and reduce fever) at 9:22 PM. The MAR also revealed the patient was medicated with Oxycodone 10 mg at this time. At 9:52 PM the patient's temperature was elevated at 102 degrees Fahrenheit. Again, the medical record lacked documentation a provider was notified. At 11:56 PM the patient's temperature remained elevated at 100.8 degrees Fahrenheit. At 1:43 AM the patient's temperature was 101.4 degrees Fahrenheit and one minute later, his pulse rate was 121 beats per minute. At 5:34 AM the patient's temperature was 103.3 degrees and at 5:35 AM, the patient's pulse rate was 128 beats per minute. The medical record lacked documentation a provider was notified of the abnormal vital signs.

A physician's order on admission instructed the nurses to notify a provider of a temperature greater than 101, a heart rate greater than 120, a heart rate less than 50, systolic blood pressure greater than 180, systolic blood pressure less than 110, diastolic blood pressure greater than 80, diastolic blood pressure less than 40, respiratory rate greater than 30, respiratory rate less than 10, oxygen saturation less than 80%, or urine output less than 200 mL.

Staff A was interviewed on 1/27/23 at 2:45 PM. It was confirmed that the staff nurses did not follow the physician's order as the medical record lacked documentation a provider was notified of the patient's abnormal vital signs.